Sustained release drug delivery systems and related methods

ABSTRACT

The present disclosure provides for methods of producing analgesia in a subject. In some cases, methods produce analgesia in a subject undergoing arthroscopic subacromial decompression surgery. The present disclosure also relates to improved sustained release drug delivery systems. In some cases, a composition comprises an active pharmaceutical agent; at least one of sucrose acetate isobutyrate and a polyorthoester; an organic solvent; and 2,6-dimethylaniline, wherein the 2,6-dimethylaniline is present at a level less than 500 ppm. In some cases, a composition comprises bupivacaine N-oxide at a level less than 1 wt %, based on weight of the composition. In some cases, a composition comprises metal present at a level less than 5 ppm. Dosage forms and methods are also provided.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application claims the benefit of priority to U.S. Provisional Patent Application Ser. No. 63/136,616 filed on Jan. 12, 2021, the disclosure of which application is herein incorporated by reference.

TECHNICAL FIELD

The present disclosure relates generally to sustained release drug delivery systems.

BACKGROUND

Biodegradable carriers for drug delivery are useful because they obviate the need to remove the drug-depleted device. Examples of biodegradable drug delivery systems include systems for controlled delivery of active pharmaceutical agents, e.g., local anesthetics, disclosed in U.S. Pat. Nos. 8,846,072 and 10,213,510, which are herein incorporated by reference in their entireties.

There remains, however, a need for improved drug delivery systems and methods of administration and storage. For instance, there remains a need for drug delivery systems having improved storage stability and safety in use.

SUMMARY OF THE INVENTION

The present disclosure provides for methods of producing analgesia in a subject. In some cases, methods produce analgesia in a subject undergoing at least one of arthroscopic subacromial decompression surgery, laparoscopic surgery, arthroscopic surgery, biopsy surgery, boney surgery, orthopedic surgery, thoracic surgery, soft tissue surgery, cholecystectomy surgery, colorectal surgery, colectomy surgery, hysterectomy surgery, ovariectomy, lumpectomy, appendectomy surgery, bunionectomy surgery, hemorrhoidectomy surgery, Caesarean section surgery, total knee arthroplasty surgery, abdominoplasty surgery, nerve block, herniorrhaphy surgery, hernia surgery, inguinal hernia repair surgery, resection liver surgery, resection of small bowel surgery, resection of stomach surgery, resection of spleen surgery, resection of gall bladder surgery, and resection of colon surgery. In some cases, methods produce analgesia in a subject undergoing arthroscopic subacromial decompression surgery.

The present disclosure also provides improved drug delivery systems having reduced impurities. The present disclosure provides improved drug delivery systems having improved stability and/or safety. The inventors have determined that there also remains a need for sustained release delivery systems containing low amounts of impurities, such as 2,6-dimethylaniline, bupivacaine N-oxide, water, peroxide, benzyl acetate, benzyl isobutyrate, and/or low amounts of metal.

Other features and advantages of the present invention will be set forth in the description of invention that follows, and in part will be apparent from the description or may be learned by practice of the invention. The invention will be realized and attained by the compositions and methods particularly pointed out in the written description and claims hereof.

The following numbered aspects, while non-limiting, are exemplary of certain aspects of the present disclosure:

1. A method of producing analgesia in a subject having arthroscopic subacromial decompression surgery, comprising:

drawing up 5 mL of a bupivacaine composition into a 5 mL syringe using a 16-gauge or larger bore needle to fill the syringe, the bupivacaine composition comprising bupivacaine free base or salt thereof, optionally wherein the bupivacaine composition further comprises sucrose acetate isobutyrate and benzyl alcohol;

discarding the 16-gauge or larger bore needle; and

administering the 5 mL of the bupivacaine composition into the subacromial space of the subject using an 18-gauge or larger bore needle to produce post-surgical analgesia.

2. A method of reducing or eliminating opioid consumption in a subject having arthroscopic subacromial decompression surgery, comprising:

drawing up 5 mL of a bupivacaine composition into a 5 mL syringe using a 16-gauge or larger bore needle to fill the syringe, the bupivacaine composition comprising bupivacaine free base or salt thereof, optionally wherein the bupivacaine composition further comprises sucrose acetate isobutyrate and benzyl alcohol;

discarding the 16-gauge or larger bore needle; and

administering the 5 mL of the bupivacaine composition into the subacromial space of the subject using an 18-gauge or larger bore needle to produce post-surgical analgesia.

3. The method of aspect 1 or 2, wherein the method comprises administering the entirety of the 5 mL of the bupivacaine composition in a single dose and then not administering additional bupvicaine, and not administering any other local anesthetic, for a period of at least 72 hours after said single dose. 4. The method of aspect 3, wherein the period is a period of at least 120 hours. 5. The method of aspect 3, wherein the period is a period of at least 168 hours. 6. The method of any one of aspects 1 to 5, further comprising storing the bupivacaine composition at a temperature ranging from 15° C. to 30° C. prior to the drawing up. 7. The method of any one of aspects 1 to 6, wherein the bupivacaine composition is stored in a clear, glass vial prior to the drawing up. 8. The method of aspects 1 to 7, wherein the bupivacaine composition is stored in a 5 mL single-dose vial prior to the drawing up. 9. The method of any one of aspects 1 to 8, wherein the bupivacaine composition is stored in a vial packaged in a carton prior to the drawing up. 10. The method of aspect 9, wherein the carton is stored in a box. 11. The method of aspect 9 or 10, wherein the carton protects the bupivacaine composition from light. 12. The method of any one of aspects 9 to 11, wherein ten of the vials are packaged in the carton, which is a 10-unit carton. 13. A method of producing analgesia in a subject having at least one of arthroscopic subacromial decompression surgery, laparoscopic surgery, arthroscopic surgery, biopsy surgery, boney surgery, orthopedic surgery, thoracic surgery, soft tissue surgery, cholecystectomy surgery, colorectal surgery, colectomy surgery, hysterectomy surgery, ovariectomy, lumpectomy, appendectomy surgery, bunionectomy surgery, hemorrhoidectomy surgery, Caesarean section surgery, total knee arthroplasty surgery, abdominoplasty surgery, nerve block, herniorrhaphy surgery, hernia surgery, inguinal hernia repair surgery, resection liver surgery, resection of small bowel surgery, resection of stomach surgery, resection of spleen surgery, resection of gall bladder surgery, and resection of colon surgery, comprising:

storing a bupivacaine composition at a temperature ranging from 15° C. to 30° C., wherein the bupivacaine composition comprises bupivacaine free base or salt thereof, optionally wherein the bupivacaine composition further comprises sucrose acetate isobutyrate and benzyl alcohol; and

administering the bupivacaine composition, optionally 1 mL to 20 mL of the bupivacaine composition, to the subject to produce post-surgical analgesia, optionally administering 5 mL of the bupivacaine composition into the subacromial space of the subject to produce post-surgical analgesia.

14. The method of aspect 13, wherein said administering the bupivacaine composition is administering the bupivacaine composition to the subject to produce post-surgical analgesia. 15. The method of aspect 13, wherein said administering the bupivacaine composition is administering 1 mL to 20 mL of the bupivacaine composition to the subject to produce post-surgical analgesia. 16. The method of aspect 13, wherein said administering the bupivacaine composition is administering 5 mL of the bupivacaine composition into the subacromial space of the subject to produce post-surgical analgesia. 17. A method of reducing or eliminating opioid consumption in a subject having at least one of arthroscopic subacromial decompression surgery, laparoscopic surgery, arthroscopic surgery, biopsy surgery, boney surgery, orthopedic surgery, thoracic surgery, soft tissue surgery, cholecystectomy surgery, colorectal surgery, colectomy surgery, hysterectomy surgery, ovariectomy, lumpectomy, appendectomy surgery, bunionectomy surgery, hemorrhoidectomy surgery, Caesarean section surgery, total knee arthroplasty surgery, abdominoplasty surgery, nerve block, herniorrhaphy surgery, hernia surgery, inguinal hernia repair surgery, resection liver surgery, resection of small bowel surgery, resection of stomach surgery, resection of spleen surgery, resection of gall bladder surgery, and resection of colon surgery, comprising:

storing a bupivacaine composition at a temperature ranging from 15° C. to 30° C., wherein the bupivacaine composition comprises bupivacaine free base or salt thereof, optionally wherein the bupivacaine composition further comprises sucrose acetate isobutyrate and benzyl alcohol; and

administering the bupivacaine composition, optionally 1 mL to 20 mL of the bupivacaine composition, to the subject to produce post-surgical analgesia, optionally administering 5 mL of the bupivacaine composition into the subacromial space of the subject to produce post-surgical analgesia.

18. The method of aspect 17, wherein said administering the bupivacaine composition is administering the bupivacaine composition to the subject to produce post-surgical analgesia. 19. The method of aspect 17, wherein said administering the bupivacaine composition is administering 1 mL to 20 mL of the bupivacaine composition to the subject to produce post-surgical analgesia. 20. The method of aspect 17, wherein said administering the bupivacaine composition is administering 5 mL of the bupivacaine composition into the subacromial space of the subject to produce post-surgical analgesia. 21. The method of aspect 16 or 20, further comprising drawing up the 5 mL of the bupivacaine composition into a 5 mL syringe using a 16-gauge or larger bore needle to fill the syringe prior to the administering. 22. The method of aspect 21, further comprising discarding the 16-gauge or larger bore needle prior to the administering. 23. The method of any one of aspects 16 and 20 to 22, wherein the administering comprises administering the 5 mL of the bupivacaine composition into the subacromial space of the subject using an 18-gauge or larger bore needle. 24. The method of any one of aspects 13 to 23, wherein the method comprises administering the entirety of the bupivacaine composition in a single dose and then not administering additional bupvicaine, and not administering any other local anesthetic, for a period of at least 72 hours after said single dose. 25. The method of aspect 24, wherein the period is a period of at least 120 hours. 26. The method of aspect 24, wherein the period is a period of at least 168 hours. 27. The method of any one of aspects 13 to 26, wherein the storing comprises storing the bupivacaine composition in a clear, glass vial. 28. The method of any one of aspects 13 to 27, wherein the storing comprises storing the bupivacaine composition in a 5 mL single-dose vial. 29. The method of any one of aspects 13 to 28, wherein the storing comprises storing the bupivacaine composition in a vial packaged in a carton. 30. The method of aspect 29, wherein the carton is stored in a box. 31. The method of aspect 29 or 30, wherein the carton protects the bupivacaine composition from light. 32. The method of any one of aspects 29 to 31, wherein ten of the vials are packaged in the carton, which is a 10-unit carton. 33. A method of producing analgesia in a subject having at least one of arthroscopic subacromial decompression surgery, laparoscopic surgery, arthroscopic surgery, biopsy surgery, boney surgery, orthopedic surgery, thoracic surgery, soft tissue surgery, cholecystectomy surgery, colorectal surgery, colectomy surgery, hysterectomy surgery, ovariectomy, lumpectomy, appendectomy surgery, bunionectomy surgery, hemorrhoidectomy surgery, Caesarean section surgery, total knee arthroplasty surgery, abdominoplasty surgery, nerve block, herniorrhaphy surgery, hernia surgery, inguinal hernia repair surgery, resection liver surgery, resection of small bowel surgery, resection of stomach surgery, resection of spleen surgery, resection of gall bladder surgery, and resection of colon surgery, comprising:

storing a bupivacaine composition in a clear, glass vial retained in a carton that protects the bupivacaine composition from light, wherein the bupivacaine composition comprises bupivacaine free base or salt thereof, optionally the bupivacaine composition further comprises sucrose acetate isobutyrate and benzyl alcohol; and

administering the bupivacaine composition, optionally 1 mL to 20 mL of the bupivacaine composition, to the subject to produce post-surgical analgesia, optionally administering 5 mL of the bupivacaine composition into the subacromial space of the subject to produce post-surgical analgesia.

34. A method of reducing or eliminating opioid consumption in a subject having at least one of arthroscopic subacromial decompression surgery, laparoscopic surgery, arthroscopic surgery, biopsy surgery, boney surgery, orthopedic surgery, thoracic surgery, soft tissue surgery, cholecystectomy surgery, colorectal surgery, colectomy surgery, hysterectomy surgery, ovariectomy, lumpectomy, appendectomy surgery, bunionectomy surgery, hemorrhoidectomy surgery, Caesarean section surgery, total knee arthroplasty surgery, abdominoplasty surgery, nerve block, herniorrhaphy surgery, hernia surgery, inguinal hernia repair surgery, resection liver surgery, resection of small bowel surgery, resection of stomach surgery, resection of spleen surgery, resection of gall bladder surgery, and resection of colon surgery, comprising:

storing a bupivacaine composition in a clear, glass vial retained in a carton that protects the bupivacaine composition from light, wherein the bupivacaine composition comprises bupivacaine free base or salt thereof, optionally the bupivacaine composition further comprises sucrose acetate isobutyrate and benzyl alcohol; and

administering the bupivacaine composition, optionally 1 mL to 20 mL of the bupivacaine composition, to the subject to produce post-surgical analgesia, optionally administering 5 mL of the bupivacaine composition into the subacromial space of the subject to produce post-surgical analgesia.

35. The method of aspect 33 or 34, wherein the vial is a 5 mL single-dose vial. 36. The method of any one of aspects 33 to 35, wherein the vial is packaged in the carton. 37. The method of aspect 36, wherein the carton is stored in a box. 38. The method of aspect 36 or 37, wherein ten of the vials are packaged in the carton, which is a 10-unit carton. 39. The method of any one of aspects 33 to 38, further comprising storing the bupivacaine composition at a temperature ranging from 15° C. to 30° C. 40. The method of any one of aspects 33 to 39, wherein said administering the bupivacaine composition is administering the bupivacaine composition to the subject to produce post-surgical analgesia. 41. The method of any one of aspects 33 to 39, wherein said administering the bupivacaine composition is administering 1 mL to 20 mL of the bupivacaine composition to the subject to produce post-surgical analgesia. 42. The method of any one of aspects 33 to 39, wherein said administering the bupivacaine composition is administering 5 mL of the bupivacaine composition into the subacromial space of the subject to produce post-surgical analgesia. 43. The method of aspect 42, further comprising drawing up the 5 mL of the bupivacaine composition into a 5 mL syringe using a 16-gauge or larger bore needle to fill the syringe. 44. The method of aspect 43, further comprising discarding the 16-gauge or larger bore needle. 45. The method of any one of aspects 42 to 44, wherein the administering comprises administering the 5 mL of the bupivacaine composition into the subacromial space of the subject using an 18-gauge or larger bore needle. 46. The method of any one of aspects 33 to 45, wherein the method comprises administering the entirety of the bupivacaine composition in a single dose and then not administering additional bupvicaine, and not administering any other local anesthetic, for a period of at least 72 hours after said single dose. 47. The method of aspect 46, wherein the period is a period of at least 120 hours. 48. The method of aspect 46, wherein the period is a period of at least 168 hours. 49. The method of any one of aspects 1 to 48, wherein the subject is at least 18 years of age. 50. The method of any one of aspects 1 to 49, wherein the bupivacaine free base or salt thereof comprises bupivacaine free base. 51. The method of any one of aspects 1 to 50, wherein the bupivacaine composition comprises from 125 mg/mL to 150 mg/mL of bupivacaine free base equivalent. 52. The method of any one of aspects 1 to 51, wherein the bupivacaine composition comprises 132 mg/mL of bupivacaine free base equivalent. 53. The method of any one of aspects 1 to 52, wherein the bupivacaine composition comprises from 600 mg to 700 mg of bupivacaine free base equivalent. 54. The method of any one of aspects 1 to 53, wherein the bupivacaine composition comprises 660 mg of bupivacaine free base equivalent. 55. The method of any one of aspects 1 to 54, wherein the bupivacaine composition is sterile. 56. The method of any one of aspects 1 to 55, wherein the bupivacaine composition is nonpyrogenic. 57. The method of any one of aspects 1 to 56, wherein the bupivacaine composition is a clear, light yellow to amber solution. 58. The method of any one of aspects 1 to 58, wherein the bupivacaine composition color intensifies with storage time within a color range of light yellow to amber. 59. The method of aspect 58, wherein the color range is not associated with a change in potency. 60. The method any one of aspects 1 to 59, wherein the bupivacaine composition comprises sucrose acetate isobutyrate present at a level ranging from 60 wt % to 70 wt %, based on weight of the bupivacaine composition. 61. The method of aspect 60, wherein when the composition is stored in a sealed, upright, clear glass vial at 25° C./60% RH for 20 months, the sucrose acetate isobutyrate is present at the level, i.e., the sucrose acetate isobutyrate remains at a level ranging from 60 wt % to 70 wt %, based on weight of the bupivacaine composition, during storage in a sealed, upright, clear glass vial at 25° C./60% RH for 20 months or 24 months. 62. The method any one of aspects 1 to 61, wherein the bupivacaine composition comprises sucrose acetate isobutyrate present at a level of about 66 wt %, based on weight of the bupivacaine composition. 63. The method of any one of aspects 1 to 62, wherein the bupivacaine composition is prepared using sucrose acetate isobutyrate having peroxide that is present at a level less than 200 ppm. 64. The method of any one of aspects 1 to 63, wherein the bupivacaine composition comprises 2,6-dimethylaniline present at a level less than 500 ppm. 65. The method of aspect 64, wherein when the composition is stored in a sealed, upright, clear glass vial at 25° C./60% RH for 20 months or 24 months, the 2,6-dimethylaniline is present at the level. 66. The method any one of aspects 1 to 65, wherein the bupivacaine composition comprises bupivacaine N-oxide present at a level less than 1 wt %, based on weight of the bupivacaine composition. 67. The method of aspect 66, wherein when the composition is stored in a sealed, upright, clear glass vial at 25° C./60% RH for 20 months or 24 months, the bupivacaine N-oxide is present at the level. 68. The method any one of aspects 1 to 67, wherein the bupivacaine composition comprises a metal present at a level less than 5 ppm. 69. The method of aspect 68, wherein when the composition is stored in a sealed, upright, clear glass vial at 25° C./60% RH for 20 months or 24 months, the metal is present at the level. 70. The method any one of aspects 1 to 69, wherein the bupivacaine composition comprises water present at a level less than 0.5 wt %, based on weight of the bupivacaine composition. 71. The method of aspect 70, wherein when the bupivacaine composition is stored in a sealed, upright, clear glass vial at 25° C./60% RH for 20 months or 24 months, the water is present at the level. 72. The method any one of aspects 1 to 71, wherein the bupivacaine composition comprises benzyl acetate present at a level less than 100 mg/mL. 73. The method of aspect 72, wherein when the bupivacaine composition is stored in a sealed, upright, clear glass vial at 25° C./60% RH for 20 months or 24 months, the benzyl acetate is present at the level. 74. The method any one of aspects 1 to 73, wherein the bupivacaine composition comprises benzyl isobutyrate present at a level less than 50 mg/mL. 75. The method of aspect 74, wherein when the bupivacaine composition is stored in a sealed, upright, clear glass vial at 25° C./60% RH for 20 months or 24 months, the benzyl isobutyrate is present at the level. 76. The method of any one of aspects 1 to 75, wherein the bupivacaine composition has been stored at a temperature ranging from 20° C. to 25° C. prior to the administering. 77. The method of any one of aspects 1 to 76, wherein the bupivacaine composition is administered undiluted. 78. The method of any one of aspects 1 to 77, wherein the bupivacaine composition does not comprise any additional drugs. 79. The method of any one of aspects 1 to 77, wherein the bupivacaine composition does not comprise any additional local anesthetics. 80. The method of any one of aspects 1 to 79, wherein the bupivacaine composition consists of the bupivacaine free base, sucrose acetate isobutyrate, and benzyl alcohol. 81. The method of any one of aspects 1 to 80, wherein the method comprises arthroscopically visualizing the subacromial space prior to administering the bupivacaine composition. 82. The method of any one of aspects 1 to 81, further comprising confirming proper placement of the needle tip in the subacromial space before administering the bupivacaine composition. 83. The method of aspect 82, wherein the confirming proper placement of the needle tip comprises arthroscopic visualization to confirm placement of the needle tip in the subacromial space before administering the bupivacaine composition. 84. The method of any one of aspects 1 to 83, wherein the administering occurs at the end of arthroscopic shoulder surgery. 85. The method of any one of aspects 1 to 84, wherein the administering comprises inserting an 18-gauge or larger bore needle into the subject through an arthroscopic port to reach the subacromial space of the subject. 86. The method of any one of aspects 1 to 84, wherein the administering comprises inserting an 18-gauge or larger bore needle into the subject through intact skin to reach the subacromial space of the subject. 87. The method of any one of aspects 1 to 86, wherein the administering occurs at a facility comprising trained personnel and equipment for treating subjects who show evidence of neurological or cardiac toxicity. 88. The method of any one of aspects 1 to 87, wherein bupivacaine persists in plasma not more than 168 hours after the administering. 89. The method of any one of aspects 1 to 88, wherein the method provides a mean bupivacaine maximum plasma concentration (C_(max)) of not more than 2850 ng/mL. 90. The method of any one of aspects 1 to 89, wherein the method provides a mean bupivacaine maximum plasma concentration (C_(max)) ranging from 200 ng/mL to 1500 ng/mL. 91. The method of any one of aspects 1 to 89, wherein the method provides a mean bupivacaine maximum plasma concentration (C_(max)) ranging from 1000 ng/mL to 1500 ng/mL. 92. The method of any one of aspects 1 to 91, wherein the method provides a mean bupivacaine AUC(0-t) ranging from 7000 h*ng/mL to 55,000 h*ng/mL. 93. The method of any one of aspects 1 to 91, wherein the method provides a mean bupivacaine AUC(0-t) ranging from 20,000 h*ng/mL to 55,000 h*ng/mL. 94. The method of any one of aspects 1 to 93, wherein the method provides a mean bupivacaine Tmax ranging from 1 hour to 24 hours. 95. The method of any one of aspects 1 to 93, wherein the method provides a mean bupivacaine Tmax ranging from greater than 6 hours to 9 hours. 96. The method of any one of aspects 1 to 95, wherein the method provides a mean bupivacaine half-life ranging from 10 hours to 35 hours. 97. The method of any one of aspects 1 to 95, wherein the method provides a mean bupivacaine half-life ranging from 16.4 hours to 26.1 hours. 98. The method of any one of aspects 1 to 95, wherein the method provides a mean bupivacaine half-life ranging from 17 hours to 35 hours. 99. The method of any one of aspects 1 to 98, wherein there is no bupivacaine composition leakage from the subject after the administering. 100. The method of any one of aspects 1 to 99, wherein benzyl alcohol persists in plasma for not more than 12 hours after the administering. 101. The method of any one of aspects 1 to 100, wherein the post-surgical analgesia persists for up to 72 hours following the arthroscopic subacromial decompression. 102. The method of any one of aspects 1 to 101, further comprising identifying the subject as being in need of at least one of subacromial decompression surgery, arthroscopic subacromial decompression surgery, laparoscopic surgery, arthroscopic surgery, biopsy surgery, boney surgery, orthopedic surgery, thoracic surgery, soft tissue surgery, cholecystectomy surgery, colorectal surgery, colectomy surgery, hysterectomy surgery, ovariectomy, lumpectomy, appendectomy surgery, bunionectomy surgery, hemorrhoidectomy surgery, Caesarean section surgery, total knee arthroplasty surgery, abdominoplasty surgery, nerve block, herniorrhaphy surgery, hernia surgery, inguinal hernia repair surgery, resection liver surgery, resection of small bowel surgery, resection of stomach surgery, resection of spleen surgery, resection of gall bladder surgery, and resection of colon surgery. 103. The method of any one of aspects 1 to 102, further comprising monitoring cardiovascular vital signs of the subject after the administering. 104. The method of any one of aspects 1 to 103, further comprising monitoring respiratory vital signs of the subject after the administering. 105. The method of any one of aspects 1 to 104, further comprising monitoring state of consciousness of the subject after the administering. 106. The method of any one of aspects 1 to 105, further comprising monitoring the subject for central nervous system reactions after the administering. 107. The method of any one of aspects 1 to 106, further comprising monitoring the subject for cardiovascular reactions after the administering. 108. The method of any one of aspects 1 to 107, further comprising monitoring the subject for allergic reactions after the administering. 109. The method of any one of aspects 1 to 108, further comprising monitoring the subject for methemoglobinemia after the administering. 110. The method of any one of aspects 1 to 109, wherein the subject is identified as being at risk for developing methemoglobinemia. 111. The method of any one of aspects 1 to 110, wherein the subject is diagnosed as having a glucose-6-phosphate dehydrogenase deficiency. 112. The method of any one of aspects 1 to 111, wherein the subject is diagnosed as having cardiac or pulmonary compromise. 113. The method of any one of aspects 1 to 112, further comprising observing the subject for one or more symptoms of methemoglobinemia. 114. The method of aspect 113, wherein the one or more symptoms of methemoglobinemia comprise at least one of cyanotic skin discoloration, discoloration of blood, seizure, coma, and heart arrythmia. 115. The method of any one of aspects 1 to 114, further comprising informing the subject that bupivacaine-containing products can cause temporary loss of sensation or motor activity in the area of infiltration. 116. The method of any one of aspects 1 to 115, further comprising informing the subject of adverse reactions listed in a package insert for the bupivacaine composition. 117. The method of any one of aspects 1 to 116, further comprising identifying the subject to be pregnant and advising the subject of potential risks to the fetus prior to the administering. 118. The method of any one of aspects 1 to 117, wherein the subject does not have a history of hypersensitivity to any amide local anesthetic. 119. The method of aspect 118, wherein the subject does not have a history of hypersensitivity to bupivacaine free base or salt thereof. 120. The method of any one of aspects 1 to 119, wherein the subject does not have a history of anaphylactic reactions to any amide local anesthetic. 121. The method of aspect 120, wherein the subject does not have a history of anaphylactic reactions to bupivacaine free base or salt thereof. 122. The method of any one of aspects 1 to 121, wherein the subject does not have a history of serious skin reactions to any amide local anesthetic. 123. The method of aspect 122, wherein the subject does not have a history of serious skin reactions tobupivacaine free base or salt thereof. 124. The method of any one of aspects 1 to 123, wherein the subject does not have a history of hypersensitivity to sucrose acetate isobutyrate. 125. The method of any one of aspects 1 to 124, wherein the subject does not have a history of anaphylactic reactions to sucrose acetate isobutyrate. 126. The method of any one of aspects 1 to 125, wherein the subject does not have a history of serious skin reactions to sucrose acetate isobutyrate. 127. The method of any one of aspects 1 to 126, wherein the subject does not have a history of hypersensitivity to benzyl alcohol. 128. The method of any one of aspects 1 to 127, wherein the subject does not have a history of anaphylactic reactions to benzyl alcohol. 129. The method of any one of aspects 1 to 128, wherein the subject does not have a history of serious skin reactions to benzyl alcohol. 130. The method of any one of aspects 1 to 129, wherein an amount of opioid administered within 72 hours of administering the bupivacaine composition is less than the mean or median amount administered to otherwise identical subjects that are not administered the bupivacaine composition. 131. The method of any one of aspects 1 to 129, wherein an amount of opioid administered within 72 hours of administering the bupivacaine composition is less than 12 mg, based on an IV morphine equivalent dose. 132. The method of any one of aspects 1 to 129, wherein an amount of opioid administered within 72 hours of administering the bupivacaine composition is 8 mg or less, based on an IV morphine equivalent dose. 133. The method of any one of aspects 1 to 129, further comprising administering in response to a request by the subject a further analgesic in an amount sufficient to treat post-surgical pain in the subject from 0 hours to 72 hours after administering the bupivacaine composition. 134. The method of aspect 133, wherein the further analgesic comprises an opioid analgesic. 135. The method of aspect 134, wherein the opioid analgesic comprises morphine. 136. The method of aspect 135, wherein the method comprises intravenously administering 2 mg of morphine to the subject. 137. The method of aspect 135, wherein the method comprises orally administering 10 mg of morphine to the subject. 138. The method of any one of aspects 1 to 129 and 133 to 137, further comprising administering an amount of opioid rescue analgesia within 72 hours of administering the bupivacaine composition, the amount of opioid rescue analgesia based on an IV morphine equivalent dose. 139. The method of aspect 138, wherein the amount is less than the mean amount administered to otherwise identical subjects that are not administered the bupivacaine composition. 140. The method of aspect 138, wherein the amount is less than 12 mg. 141. The method of aspect 138, wherein the amount is 8 mg or less. 142. The method of any one of aspects 1 to 141, wherein the bupivacaine composition does not contain particulate matter. 143. The method of any one of aspects 1 to 142, wherein the method does not comprise autoclaving the bupivacaine composition. 144. The method of any one of aspects 1 to 143, wherein the method does not comprise mixing the bupivacaine composition. 145. The method of any one of aspects 1 to 144, wherein the method does not comprise diluting the bupivacaine composition. 146. The method of any one of aspects 1 to 145, wherein the method does not comprise obstetrical paracervical block anesthesia. 147. The method of any one of aspects 1 to 146, wherein the method does not comprise epidural administration of the bupivacaine composition. 148. The method of any one of aspects 1 to 147, wherein the method does not comprise intrathecal administration of the bupivacaine composition. 149. The method of any one of aspects 1 to 148, wherein the method does not comprise intravascular administration of the bupivacaine composition. 150. The method of any one of aspects 1 to 149, wherein the method does not comprise intra-articular administration of the bupivacaine composition. 151. The method of any one of aspects 1 to 150, wherein the method does not comprise administration of the bupivacaine composition into the glenohumeral intra-articular space of the subject. 152. The method of any one of aspects 1 to 151, wherein the bupivacaine composition is arthroscopically administered to the subject in a manner sufficient to avoid the glenohumeral intra-articular space. 153. The method of any one of aspects 1 to 152, wherein the method does not comprise a nerve block. 154. The method of any one of aspects 1 to 153, wherein the method does not comprise a regional nerve block. 155. The method of any one of aspects 1 to 154, wherein the method does not comprise neuraxial nerve blockade. 156. The method of any one of aspects 1 to 155, wherein the method does not comprise peripheral nerve blockade. 157. The method of any one of aspects 1 to 156, wherein the method does not comprise pre-incisional or pre-procedural locoregional anesthetic techniques that require deep and complete sensory block in the area of administration. 158. The method of aspects 1 to 157, wherein the bupivacaine composition comprises 2,6-dimethylaniline present at a level less than 300 ppm. 159. The method of any one of aspects 1 to 158, wherein the bupivacaine composition comprises 2,6-dimethylaniline present in the bupivacaine composition at a level less than 200 ppm. 160. The method of any one of aspects 1 to 159, wherein the bupivacaine composition comprises 2,6-dimethylaniline present in the bupivacaine composition at a level less than 100 ppm. 161. The method of any one of aspects 1 to 160, wherein the bupivacaine composition comprises 2,6-dimethylaniline present in the bupivacaine composition at a level less than 15 ppm, less than 12 ppm, less than 10 ppm, or less than 5 ppm. 162. The method of any one of aspects 1 to 161, wherein the bupivacaine composition comprises 2,6-dimethylaniline present in the bupivacaine composition at a level ranging from 0.2 ppm to 500 ppm. 163. The method of any one of aspects 1 to 162, wherein the bupivacaine composition comprises 2,6-dimethylaniline present in the bupivacaine composition at a level ranging from 0.3 ppm to 200 ppm. 164. The method of any one of aspects 1 to 163, wherein the bupivacaine composition comprises 2,6-dimethylaniline present in the bupivacaine composition at a level ranging from 0.4 ppm to 100 ppm. 165. The method of any one of aspects 1 to 164, wherein the bupivacaine composition comprises 2,6-dimethylaniline present in the bupivacaine composition at a level ranging from 0.5 ppm to 10 ppm or 2 ppm to 8 ppm. 166. The method of any one of aspects 1 to 165, wherein the bupivacaine composition comprises bupivacaine N-oxide present in the bupivacaine composition at a level less than 0.7 wt % or less than 0.5 wt %, based on weight of the bupivacaine composition. 167. The method of any one of aspects 1 to 166, wherein the bupivacaine composition comprises bupivacaine N-oxide present in the bupivacaine composition at a level less than 0.4 wt %, based on weight of the bupivacaine composition. 168. The method of any one of aspects 1 to 167, wherein the bupivacaine composition comprises bupivacaine N-oxide present in the bupivacaine composition at a level ranging from 0.01 wt % to 1 wt %, based on weight of the bupivacaine composition. 169. The method of any one of aspects 1 to 168, wherein the bupivacaine composition comprises bupivacaine N-oxide present in the bupivacaine composition at a level ranging from 0.05 wt % to 0.4 wt % or 0.1 wt % to 0.4 wt %, based on weight of the bupivacaine composition. 170. The method of any one of aspects 1 to 169, wherein the bupivacaine composition comprises bupivacaine N-oxide present in the bupivacaine composition at a level ranging from 0.1 wt % to 0.2 wt %, based on weight of the bupivacaine composition. 171. The method of any one of aspects 1 to 170, wherein the bupivacaine composition comprises metal is present in the bupivacaine composition at a level less than 4 ppm. 172. The method of any one of aspects 1 to 171, wherein the bupivacaine composition comprises metal is present in the bupivacaine composition at a level less than 3 ppm. 173. The method of any one of aspects 1 to 172, wherein the bupivacaine composition comprises metal present in the bupivacaine composition at a level ranging from 0.01 ppm to 4 ppm. 174. The method of any one of aspects 1 to 173, wherein the bupivacaine composition comprises metal present in the bupivacaine composition at a level ranging from 0.05 ppm to 3 ppm. 175. The method of any one of aspects 1 to 174, wherein the bupivacaine composition comprises metal present in the bupivacaine composition at a level ranging from 0.1 ppm to 2 ppm. 176. The method of any one of aspects 1 to 175, wherein the bupivacaine composition comprises water present in the bupivacaine composition at a level less than 0.4 wt %, based on weight of the bupivacaine composition. 177. The method of any one of aspects 1 to 176, wherein the bupivacaine composition comprises water present in the bupivacaine composition at a level less than 0.3 wt %, based on weight of the bupivacaine composition. 178. The method of any one of aspects 1 to 177, wherein the bupivacaine composition comprises water present in the bupivacaine composition at a level ranging from 0.03 wt % to 0.4 wt %, based on weight of the bupivacaine composition. 179. The method of any one of aspects 1 to 178, wherein the bupivacaine composition comprises water present in the bupivacaine composition at a level ranging from 0.05 wt % to 0.35 wt %, based on weight of the bupivacaine composition. 180. The method of any one of aspects 1 to 179, wherein the bupivacaine composition comprises water present in the bupivacaine composition at a level ranging from 0.08 wt % to 0.3 wt %, based on weight of the bupivacaine composition. 181. The method of any one of aspects 1 to 180, wherein the bupivacaine composition comprises benzyl acetate present in the bupivacaine composition at a level less than 50 mg/mL. 182. The method of any one of aspects 1 to 181, wherein the bupivacaine composition comprises benzyl acetate present in the bupivacaine composition at a level less than 20 mg/mL or less than 15 mg/mL. 183. The method of any one of aspects 1 to 182, wherein the bupivacaine composition comprises benzyl acetate present in the bupivacaine composition at a level ranging from 0.1 mg/mL to 80 mg/mL. 184. The method of any one of aspects 1 to 183, wherein the bupivacaine composition comprises benzyl acetate present in the bupivacaine composition at a level ranging from 0.5 mg/mL to 40 mg/mL. 185. The method of any one of aspects 1 to 184, wherein the bupivacaine composition comprises benzyl acetate present in the bupivacaine composition at a level ranging from 1 mg/mL to 20 mg/mL or 1 mg/mL to 15 mg/mL. 186. The method of any one of aspects 1 to 185, wherein the bupivacaine composition comprises benzyl isobutyrate present in the bupivacaine composition at a level less than 30 mg/mL. 187. The method of any one of aspects 1 to 186, wherein the bupivacaine composition comprises benzyl isobutyrate present in the bupivacaine composition at a level less than 10 mg/mL or less than 8 mg/mL. 188. The method of any one of aspects 1 to 187, wherein the bupivacaine composition comprises benzyl isobutyrate present in the bupivacaine composition at a level ranging from 0.1 mg/mL to 40 mg/mL. 189. The method of any one of aspects 1 to 188, wherein the bupivacaine composition comprises benzyl isobutyrate present in the bupivacaine composition at a level ranging from 0.5 mg/mL to 30 mg/mL. 190. The method of any one of aspects 1 to 189, wherein the bupivacaine composition comprises benzyl isobutyrate is present in the bupivacaine composition at a level ranging from 1 mg/mL to 10 mg/mL or 1 mg/mL to 8 mg/mL. 191. The method of any one of aspects 1 to 190, wherein the bupivacaine composition is prepared using sucrose acetate isobutyrate having peroxide that is present at a level less than 200 ppm; 192. The method of any one of aspects 1 to 191, wherein the bupivacaine composition is prepared using sucrose acetate isobutyrate having peroxide that is present at a level less than 100 ppm. 193. The method of any one of aspects 1 to 192, wherein the bupivacaine composition is prepared using sucrose acetate isobutyrate having peroxide that is present at a level less than 80 ppm or less than 60 ppm. 194. The method of any one of aspects 1 to 193, wherein the bupivacaine composition is prepared using sucrose acetate isobutyrate having peroxide that is present at a level ranging from 1 ppm to 100 ppm. 195. The method of any one of aspects 1 to 194, wherein the bupivacaine composition is prepared using sucrose acetate isobutyrate having peroxide that is present at a level ranging from 2 ppm to 80 ppm. 196. The method of any one of aspects 1 to 195, wherein the bupivacaine composition is prepared using sucrose acetate isobutyrate having peroxide that is present at a level ranging from 3 ppm to 60 ppm. 197. The method of any one of aspects 1 to 196, wherein the bupivacaine composition is prepared using an organic solvent having peroxide that is present at a level less than 100 ppm. 198. The method of aspect 197, wherein the organic solvent comprises benzyl alcohol. 199. The method of any one of aspects 1 to 198, wherein the bupivacaine composition is prepared using organic solvent having peroxide that is present at a level less than 85 ppm. 200. The method of any one of aspects 1 to 199, wherein the bupivacaine composition is prepared using organic solvent having peroxide that is present at a level less than 10 ppm. 201. The method of any one of aspects 1 to 200, wherein the bupivacaine composition is prepared using organic solvent having peroxide that is present at a level ranging from 1 ppm to 90 ppm. 202. The method of any one of aspects 1 to 201, wherein the bupivacaine composition is prepared using organic solvent having peroxide that is present at a level ranging from 2 ppm to 85 ppm. 203. The method of any one of aspects 1 to 202, wherein the bupivacaine composition is prepared using organic solvent having peroxide present at a level ranging from 3 ppm to 10 ppm. 204. The method of any of aspects 1 to 203, wherein the bupivacaine composition comprises peroxide at a level less than 200 ppm. 205. The method of any of aspects 1 to 204, wherein the bupivacaine composition comprises peroxide at a level less than 100 ppm. 206. The method of any of aspects 1 to 205, wherein the bupivacaine composition comprises peroxide at a level less than 50 ppm. 207. The method of any of aspects 1 to 206, wherein the bupivacaine composition comprises peroxide at a level of at least 1 ppm. 208. The method of any of aspects 1 to 207, wherein the bupivacaine composition comprises peroxide at a level of at least 5 ppm. 209. The method of any one of aspects 1 to 208, wherein the bupivacaine composition comprises sucrose acetate isobutyrate present at a level ranging from 30 wt % to 80 wt %, based on weight of the bupivacaine composition. 210. The method of any one of aspects 1 to 209, wherein the bupivacaine composition comprises sucrose acetate isobutyrate present in the bupivacaine composition at a level ranging from 40 wt % to 70 wt %, 50 wt % to 70 wt %, 61 wt % to 69 wt %, based on weight of the bupivacaine composition. 211. The method of any one of aspects 1 to 210, wherein the bupivacaine composition comprises sucrose acetate isobutyrate present in the bupivacaine composition at a level ranging from 62 wt % to 68 wt %, based on weight of the bupivacaine composition. 212. The method of any one of aspects 1 to 211, wherein the bupivacaine composition comprises sucrose acetate isobutyrate present in the bupivacaine composition at a level ranging from 63 wt % to 67 wt %, based on weight of the bupivacaine composition. 213. The method of any one of aspects 1 to 212, wherein the bupivacaine composition comprises bupivacaine or salt thereof present in the bupivacaine composition in an amount ranging from 1 wt % to 25 wt %, based on weight of the bupivacaine composition. 214. The method of any one of aspects 1 to 213, wherein the bupivacaine composition comprises bupivacaine or salt thereof present in the bupivacaine composition in an amount ranging from 5 wt % to 20 wt %, based on weight of the bupivacaine composition. 215. The method of any one of aspects 1 to 214, wherein the bupivacaine composition comprises bupivacaine or salt thereof present in the bupivacaine composition in an amount ranging from 10 wt % to 15 wt %, based on weight of the bupivacaine composition. 216. The method of any one of aspects 1 to 215, wherein the bupivacaine composition comprises bupivacaine or salt thereof present in the bupivacaine composition in an amount of about 12 wt %, based on weight of the bupivacaine composition. 217. The method of any one of aspects 1 to 216, wherein the bupivacaine composition comprises organic solvent comprising at least one member selected from benzyl alcohol, benzyl benzoate, dimethylsulfoxide, ethanol, N-methylpyrrolidone, and triacetin. 218. The method of any one of aspects 1 to 217, wherein the bupivacaine composition comprises benzyl alcohol. 219. The method of any one of aspects 1 to 218, wherein the bupivacaine composition comprises organic solvent present in the bupivacaine composition in an amount sufficient to dissolve the bupivacaine or salt thereof in the bupivacaine composition, or the organic solvent is present in the bupivacaine composition in an amount of at least 5 wt %, based on weight of the bupivacaine composition. 220. The method of any one of aspects 1 to 219, wherein the bupivacaine composition comprises organic solvent present in the bupivacaine composition in an amount of at least 10 wt %, based on weight of the bupivacaine composition. 221. The method of any one of aspects 1 to 220, wherein the bupivacaine composition comprises organic solvent present in the bupivacaine composition in an amount of at least 15 wt %, based on weight of the bupivacaine composition. 222. The method of any one of aspects 1 to 221, wherein the bupivacaine composition comprises organic solvent present in the bupivacaine composition in an amount of at least 20 wt %, based on weight of the bupivacaine composition. 223. The method of any one of aspects 1 to 222, wherein the bupivacaine composition comprises organic solvent present in the bupivacaine composition in an amount ranging from 5 wt % to 45 wt %, based on weight of the bupivacaine composition. 224. The method of any one of aspects 1 to 223, wherein the bupivacaine composition comprises organic solvent present in the bupivacaine composition in an amount ranging from 10 wt % to 35 wt %, based on weight of the bupivacaine composition. 225. The method of any one of aspects 1 to 224, wherein the bupivacaine composition comprises organic solvent present in the bupivacaine composition in an amount ranging from 15 wt % to 30 wt %, based on weight of the bupivacaine composition. 226. The method of any one of aspects 1 to 225, wherein the bupivacaine composition comprises organic solvent present in the bupivacaine composition in an amount ranging from 20 wt % to 25 wt %, based on weight of the bupivacaine composition. 227. The method of any one of aspects 1 to 226, wherein the bupivacaine composition comprises organic solvent present in the bupivacaine composition in an amount of about 22 wt %, based on weight of the bupivacaine composition. 228. The method of any one of aspects 219 to 227, wherein the organic solvent is benzyl alcohol. 229. The method of any one of aspects 1 to 228, wherein the bupivacaine composition comprises benzyl alcohol present in the bupivacaine composition in an amount of about 22 wt %, based on weight of the bupivacaine composition. 230. The method of any one of aspects 1 to 229, wherein the bupivacaine composition comprises sucrose acetate isobutyrate. 231. The method of any one of aspects 1 to 230, wherein the bupivacaine composition comprises composition comprises high viscosity liquid carrier material (HVLCM) present in the bupivacaine composition in an amount sufficient to provide sustained release of the active pharmaceutical agent from the bupivacaine composition, such as sustained release of about 72 hours, or the bupivacaine composition comprises HVLCM present in the bupivacaine composition in an amount ranging from 50 wt % to 80 wt %, based on weight of the bupivacaine composition. 232. The method of any one of aspects 1 to 231, wherein the bupivacaine composition comprises HVLCM present in the bupivacaine composition in an amount ranging from 55 wt % to 75 wt %, based on weight of the bupivacaine composition. 233. The method of any one of aspects 1 to 232, wherein the bupivacaine composition comprises HVLCM present in the bupivacaine composition in an amount ranging from 60 wt % to 70 wt %, based on weight of the bupivacaine composition. 234. The method of any one of aspects 1 to 233, wherein the bupivacaine composition comprises HVLCM present in the bupivacaine composition in an amount of about 66 wt %, based on weight of the bupivacaine composition. 235. The method of any one of aspects 1 to 234, further comprising storing the bupivacaine composition in a dosage system comprising:

a container comprising a first inert material; and

a closure capable of closing the container, the closure comprising a second inert material.

236. The method of aspect 235, wherein the dosage system does not include silicone oil. 237. The method of any one of aspects 235 and 236, wherein the second inert material comprises a fluorocarbon. 238. The method of any one of aspects 235 to 237, wherein the second inert material comprises tetrafluoroethylene. 239. The method of any one of aspects 235 to 38, wherein the second inert material comprises a fluorinated polymer. 240. The method of any one of aspects 235 to 239, wherein the closure comprises a fluorocarbon-coated stopper. 241. The method of any one of aspects 235 to 240, wherein the first inert material comprises glass. 242. The method of aspect 241, wherein the glass comprises clear glass. 243. The method of any one of aspects 241 and 242, wherein the glass is transparent to visible light. 244. The method of any one of aspects 241 to 243, wherein the glass has an optical density of 1 or less to wavelengths of light of from 400 nm to 600 nm. 245. The method of any one of aspects 241 to 244, wherein the glass has an optical density of greater than 1 to wavelengths of light of from 100 nm to 250 nm. 246. The method of any one of aspects 241 to 245, wherein the glass does not contain iron. 247. The method of any one of aspects 241 to 246, wherein the glass comprises borosilicate glass that does not contain iron. 248. The method of any one of aspects 241 to 247, wherein the glass comprises pyrex glass that does not contain iron. 249. The method of any one of aspects 235 to 248, wherein the container comprises a vial. 250. The method of any one of aspects 1 to 249, further comprising storing the bupivacaine composition in a dosage system comprising:

a first container; and

a second container within the first container, the second container comprising a first inert material and the first container reduces ambient visible light from irradiating onto the second container,

the bupivacaine composition being contained within the second container.

251. The method of aspect 250, wherein the first container comprises a box or a carton. 252. The method of aspect 251, wherein the first container is a 1-unit to 25-unit box or carton. 253. The method of aspect 252, wherein the first container is a 10-unit box or carton. 254. The method of any one of aspects 251 to 253, wherein ten of the second containers are in the first container. 255. The method of any one of aspects 251 to 254, wherein the first container is in a second box. 256. The method of any one of aspects 250 to 255, wherein the first container comprises a polymer. 257. The method of any one of aspects 250 to 256, wherein the first container comprises a thermoplastic. 258. The method of any one of aspects 250 to 257 wherein the first container comprises cellulose. 259. The method of any one of aspects 250 to 258, wherein the first container comprises clay. 260. The method of any one of aspects 250 to 259, wherein the first container comprises a material having a thickness of at least 0.5 mm or ranging from 0.4 mm to 3 mm, such as 0.5 mm to 2.5 mm, 0.5 mm to 1 mm, 0.6 mm to 0.9 mm, or 0.7 mm to 0.8 mm. 261. The method of any one of aspects 235 to 260, further comprising a gas contained within the container that contains the composition, the gas having an oxygen content of less than 10 mol % or less than 10 wt %. 262. The method of aspect 261, wherein the gas has an oxygen content ranging from 1 mol % to 10 mol % or 1 wt % to 10 wt %. 263. The method of aspect 262, wherein the gas fills a headspace within the container that contains the composition. 264. The method of any one of aspects 235 to 263, wherein the container that contains the composition comprises a layer that reduces light transmission. 265. A bupivacaine composition for use in a method as defined in any one of aspects 1 to 264. 266. The bupivacaine composition for use of aspect 265, wherein the bupivacaine composition is as defined in any one of aspects 1 to 264. 267. Use of a bupivacaine composition in the manufacture of a medicament for use in a method as defined in any one of aspects 1 to 264. 268. Use of aspect 267, wherein the bupivacaine composition is as defined in any one of aspects 1 to 264. 269. A kit comprising:

a bupivacaine composition comprising bupivacaine free base or salt thereof; and

a package insert with instructions for administering the bupivacaine composition to produce analgesia in a subject having arthroscopic subacromial decompression surgery, the package insert comprising:

-   -   instructions to draw up 5 mL of the bupivacaine composition into         a 5 mL syringe using a 16-gauge or larger bore needle to fill         the syringe;     -   instructions to discard the 16-gauge or larger bore needle; and     -   instructions to administer the 5 mL of the bupivacaine         composition into the subacromial space of the subject using an         18-gauge or larger bore needle to produce post-surgical         analgesia.         270. A kit comprising:

a bupivacaine composition comprising bupivacaine free base or salt thereof, wherein the bupivacaine composition further comprises sucrose acetate isobutyrate and benzyl alcohol; and

a package insert with instructions for administering the bupivacaine composition to reduce or eliminate opioid consumption in a subject having arthroscopic subacromial decompression surgery, the package insert comprising:

-   -   instructions to draw up 5 mL of a bupivacaine composition into a         5 mL syringe using a 16-gauge or larger bore needle to fill the         syringe;     -   instructions to discard the 16-gauge or larger bore needle; and     -   instructions to administer the 5 mL of the bupivacaine         composition into the subacromial space of the subject using an         18-gauge or larger bore needle to produce post-surgical         analgesia.         271. The kit of aspect 270, wherein the package insert further         comprises instructions to administer the entirety of the 5 mL of         the bupivacaine composition in a single dose and then not         administering additional bupvicaine, and not administering any         other local anesthetic, for a period of at least 72 hours after         said single dose.         272. The kit of aspect 271, wherein the period is a period of at         least 120 hours.         273. The kit of aspect 271, wherein the period is a period of at         least 168 hours.         274. A method of producing analgesia in a subject having at         least one of arthroscopic subacromial decompression surgery,         laparoscopic surgery, arthroscopic surgery, biopsy surgery,         boney surgery, orthopedic surgery, thoracic surgery, soft tissue         surgery, cholecystectomy surgery, colorectal surgery, colectomy         surgery, hysterectomy surgery, ovariectomy, lumpectomy,         appendectomy surgery, bunionectomy surgery, hemorrhoidectomy         surgery, Caesarean section surgery, total knee arthroplasty         surgery, abdominoplasty surgery, nerve block, herniorrhaphy         surgery, hernia surgery, inguinal hernia repair surgery,         resection liver surgery, resection of small bowel surgery,         resection of stomach surgery, resection of spleen surgery,         resection of gall bladder surgery, and resection of colon         surgery, comprising:

administering a bupivacaine composition, optionally 1 mL to 20 mL of the bupivacaine composition, to the subject to produce post-surgical analgesia, optionally administering 5 mL of the bupivacaine composition into the subacromial space of the subject to produce post-surgical analgesia,

wherein the bupivacaine composition has been stored at a temperature ranging from 15° C. to 30° C.; and

wherein the bupivacaine composition comprises bupivacaine free base or salt thereof, optionally wherein the bupivacaine composition further comprises sucrose acetate isobutyrate and benzyl alcohol.

275. A method of reducing or eliminating opioid consumption in a subject having at least one of arthroscopic subacromial decompression surgery, laparoscopic surgery, arthroscopic surgery, biopsy surgery, boney surgery, orthopedic surgery, thoracic surgery, soft tissue surgery, cholecystectomy surgery, colorectal surgery, colectomy surgery, hysterectomy surgery, ovariectomy, lumpectomy, appendectomy surgery, bunionectomy surgery, hemorrhoidectomy surgery, Caesarean section surgery, total knee arthroplasty surgery, abdominoplasty surgery, nerve block, herniorrhaphy surgery, hernia surgery, inguinal hernia repair surgery, resection liver surgery, resection of small bowel surgery, resection of stomach surgery, resection of spleen surgery, resection of gall bladder surgery, and resection of colon surgery, comprising:

administering a bupivacaine composition, optionally 1 mL to 20 mL of the bupivacaine composition, to the subject to produce post-surgical analgesia, optionally administering 5 mL of the bupivacaine composition into the subacromial space of the subject to produce post-surgical analgesia,

wherein the bupivacaine composition has been stored at a temperature ranging from 15° C. to 30° C.; and

wherein the bupivacaine composition comprises bupivacaine free base or salt thereof, optionally wherein the bupivacaine composition further comprises sucrose acetate isobutyrate and benzyl alcohol.

276. A method of producing analgesia in a subject having at least one of arthroscopic subacromial decompression surgery, laparoscopic surgery, arthroscopic surgery, biopsy surgery, boney surgery, orthopedic surgery, thoracic surgery, soft tissue surgery, cholecystectomy surgery, colorectal surgery, colectomy surgery, hysterectomy surgery, ovariectomy, lumpectomy, appendectomy surgery, bunionectomy surgery, hemorrhoidectomy surgery, Caesarean section surgery, total knee arthroplasty surgery, abdominoplasty surgery, nerve block, herniorrhaphy surgery, hernia surgery, inguinal hernia repair surgery, resection liver surgery, resection of small bowel surgery, resection of stomach surgery, resection of spleen surgery, resection of gall bladder surgery, and resection of colon surgery, comprising:

administering a bupivacaine composition, optionally 1 mL to 20 mL of the bupivacaine composition, to the subject to produce post-surgical analgesia, optionally administering 5 mL of the bupivacaine composition into the subacromial space of the subject to produce post-surgical analgesia,

wherein the bupivacaine composition has been stored in a clear, glass vial retained in a carton that protects the bupivacaine composition from light; and

wherein the bupivacaine composition comprises bupivacaine free base or salt thereof, optionally the bupivacaine composition further comprises sucrose acetate isobutyrate and benzyl alcohol.

277. A method of reducing or eliminating opioid consumption in a subject having at least one of arthroscopic subacromial decompression surgery, laparoscopic surgery, arthroscopic surgery, biopsy surgery, boney surgery, orthopedic surgery, thoracic surgery, soft tissue surgery, cholecystectomy surgery, colorectal surgery, colectomy surgery, hysterectomy surgery, ovariectomy, lumpectomy, appendectomy surgery, bunionectomy surgery, hemorrhoidectomy surgery, Caesarean section surgery, total knee arthroplasty surgery, abdominoplasty surgery, nerve block, herniorrhaphy surgery, hernia surgery, inguinal hernia repair surgery, resection liver surgery, resection of small bowel surgery, resection of stomach surgery, resection of spleen surgery, resection of gall bladder surgery, and resection of colon surgery, comprising:

administering the bupivacaine composition, optionally 1 mL to 20 mL of the bupivacaine composition, to the subject to produce post-surgical analgesia, optionally administering 5 mL of the bupivacaine composition into the subacromial space of the subject to produce post-surgical analgesia,

wherein the bupivacaine composition has been stored in a clear, glass vial retained in a carton that protects the bupivacaine composition from light; and

wherein the bupivacaine composition comprises bupivacaine free base or salt thereof, optionally the bupivacaine composition further comprises sucrose acetate isobutyrate and benzyl alcohol.

278. The kit of any one of aspects 269 to 273, wherein the package insert includes instructions for performing the method of any one of aspects 1 to 264 and 274 to 277 or use of aspect 267 or 268.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 shows pain intensity (PI) on movement over time for the intent-to-treat (ITT) population.

FIG. 2 shows geometric mean total and free bupivacaine plasma concentration following bupivacaine concentration following administration of Formulation A or standard bupivicane.

FIG. 3 shows a correlation of all individual plasma concentrations of free versus total bupivacaine for Formulation A.

FIG. 4 shows pain intensity normalized AUC was compared between treatment groups using ANCOVA with treatment group and trial site as factors and age as a covariate.

FIG. 5A shows the mean pain intensity on movement by subjects in the modified intent-to-treat (MITT) set administered Formulation A as compared to subjects administered placebo at time points post dose.

FIG. 5B depicts the mean pain intensity on movement by subjects in the per protocol (PP) set administered Formulation A as compared to subjects administered placebo at time points post dose.

FIG. 6 shows cumulative morphine equivalent dose compared between treatment groups using ANCOVA with treatment group and trial site as factors and age as a covariate.

FIG. 7 depicts the cumulative morphine equivalent dose in the MITT set administered Formulation A as compared to subjects administered placebo at time points post dose.

FIG. 8 shows mean PI_(move) over time, analyzed separately for Cohort 1 and Cohort 2.

FIG. 9 shows PI_(move) over time in a subgroup of subjects who had minimal or no glenohumeral pathology.

FIG. 10 shows that Formulation A 5 mL demonstrated a significant reduction in mean pain intensity compared with placebo of 1.3 points on a 0-10 NRS scale over 72 hours.

FIG. 11 shows that there was no statistically significant difference in either primary endpoint between Formulation A and vehicle placebo treatment groups.

FIG. 12 shows that there was no statistically significant difference in either primary endpoint between Formulation A and vehicle placebo treatment groups.

FIG. 13 shows the water content and coloration of Formulation A samples.

FIG. 14 shows a linear regression line fitted to the SAIB peroxide content data versus bupivacaine N-oxide levels.

FIG. 15 shows label strength of 4 primary (5 mL) and 4 secondary (7.5 mL) lots of samples of Formulation A over a 36-month period.

FIG. 16 shows change in bupivacaine N-oxide (measure in % bupivacaine N-oxide) in 4 primary (5 mL) and 4 secondary (7.5 mL) lots of samples of Formulation A over a 36-month period.

FIG. 17 shows presence of 2,6-dimethylaniline (measure in ppm) in 4 primary (5 mL) and 4 secondary (7.5 mL) lots of samples of Formulation A over an 18-month period (months 18-36).

FIG. 18 shows presence of 2,6-dimethylaniline in samples of Formulation A stored for a 6-month period at 3 different temperatures (25° C., 30° C. and 40° C.) and 2 different relative humidities (60% RH, 75% RH).

FIG. 19 shows presence of benzyl acetate (measure in mg/mL) in 4 primary (5 mL) and 4 secondary (7.5 mL) lots of samples of Formulation A over a 36-month period.

FIG. 20 shows presence of benzyl acetate in samples of Formulation A stored for a 6-month period at 3 different temperatures (25° C., 30° C. and 40° C.) and 2 different relative humidities (60% RH, 75% RH).

FIG. 21 shows presence of benzyl isobutyrate (measure in mg/mL) in 4 primary (5 mL) and 4 secondary (7.5 mL) lots of samples of Formulation A over a 36-month period.

FIG. 22 shows presence of benzyl isobutyrate in samples of Formulation A stored for a 6-month period at 3 different temperatures (25° C., 30° C. and 40° C.) and 2 different relative humidities (60% RH, 75% RH).

FIG. 23 shows change in percent SAIB in 4 primary (5 mL) and 4 secondary (7.5 mL) lots of samples of Formulation A over a 36-month period.

FIG. 24 shows mean cumulative release of a control formulation (N=4), −30% SAIB formulation (N=3), −40% SAIB formulation (N=3), −50% SAIB formulation (N=4), −70% SAIB formulation (N=3), and −90% SAIB formulation (N=3).

FIG. 25 shows mean cumulative release of a control formulation (N=12), +20% SAIB formulation (N=12), −20% SAIB formulation (N=12), and −70% SAIB formulation (N=12).

FIG. 26 shows mean cumulative release of a control formulation (N=12) and heat-stressed SAIB formulation (N=12).

FIGS. 27 to 29 show line graphs of mean pain intensity on movement±standard error of the mean (SEM) versus the scheduled time of pain assessment for each cohort.

FIGS. 30 to 32 show graphs of plasma bupivacaine concentration vs. time after treatment.

DETAILED DESCRIPTION

Before describing the present invention in detail, it is to be understood that this invention is not limited to particularly exemplified carrier materials or process parameters as such may, of course, vary. It is also to be understood that the terminology used herein is for the purpose of describing particular embodiments of the invention only, and is not intended to be limiting.

All publications, patents and patent applications cited herein, whether supra or infra, are hereby incorporated by reference in their entirety.

As used in this specification and the appended claims, the singular forms “a,” “an” and “the” include plural referents unless the content clearly dictates otherwise. Thus, for example, “a solvent” includes a mixture of two or more such carriers, reference to “an anesthetic” includes mixtures of two or more such agents, and the like.

As used herein, “present” at a level means that a given component, e.g., 2,6-dimethylaniline, is present at a level greater than zero.

As summarized above, aspects of the present disclosure include methods for producing analgesia in a subject. In some cases, methods include producing analgesia in a subject undergoing at least one of arthroscopic subacromial decompression surgery, laparoscopic surgery, arthroscopic surgery, biopsy surgery, boney surgery, orthospedic surgery, thoracic surgery, soft tissue surgery, cholecystectomy surgery, colorectal surgery, colectomy surgery, hysterectomy surgery, ovariectomy, lumpectomy, appendectomy surgery, bunionectomy surgery, hemorrhoidectomy surgery, Caesarean section surgery, total knee arthroplasty surgery, abdominoplasty surgery, nerve block, herniorrhaphy surgery, hernia surgery, inguinal hernia repair surgery, resection liver surgery, resection of small bowel surgery, resection of stomach surgery, resection of spleen surgery, resection of gall bladder surgery, and resection of colon surgery. In some cases, methods include producing analgesia in a subject undergoing arthroscopic subacromial decompression surgery. In certain instances, methods provide for producing post-surgical analgesia in subjects undergoing shoulder surgery that includes arthroscopic subacromial decompression surgery. In certain cases, the methods provide for post-surgical analgesia that persists for up to 72 hours following the surgery, such as for up to 72 hours after arthroscopic subacromial decompression.

The term “subject,” as used herein, refers to any vertebrate in which it is desired to provide a state of local anesthesia. The term thus broadly refers to any animal that is to be treated with the compositions of the present disclosure, such as birds, fish and mammals including humans. In certain cases, the methods of the present disclosure are suitable to provide sustained anesthesia in veterinary practice and animal husbandry, e.g., birds and mammals, whenever a long-term state of local anesthesia is convenient or desirable. In certain cases, the compositions are particularly suited for used with companion animals such as dogs or cats, and additionally may be used with horses. In preferred cases, the term “subject” intends a human subject. Furthermore, the term “subject” does not denote a particular age, and the compositions are thus suited for use with subjects of any age, such as infant, adolescent, adult and senior aged subjects. In some instances, the subject is at least 18-years of age. In some cases, the subject is in need of subacromial decompression surgery and methods may further include identifying the subject as being in need of subacromial decompression surgery.

In some cases, the administration involves needle-free administration. For instance, the administration may involve pouring. In some cases, the administration involves administration with a syringe, optionally with a catheter. In some cases, the catheter is a 14-gauge catheter having a length of 1 inch to 1.5 inch.

In some cases, the administration involves administration with one or more needles. In some cases, methods include drawing up a predetermined amount of an active agent composition into a syringe coupled to a first needle having a first bore size and administering the active agent composition to the subject with the syringe coupled to a second needle having a second bore size. In certain instances, methods include discarding the first needle and attaching the second needle to the syringe after drawing up the active agent composition into the syringe with the first needle. In certain instances, methods include discarding the first needle and connecting the second needle with the syringe after drawing up the active agent composition into the syringe with the first needle. In some instances, the bore size of the first needle coupled to the syringe is larger than the bore size of the second needle. For example, the bore size of the first needle may be 5% larger or more than the bore size of the second needle, 10% larger or more, 15% larger or more, 20% larger or more, 30% larger or more, 40% larger or more, 50% larger or more, 60% larger or more, 70% larger or more, 80% larger or more, 90% larger or more, 95 larger or more, 99% larger or more, including 1.5-fold larger or more, 2-fold larger or more, 2.5 larger or more, 3-fold larger or more, 3.5-fold larger or more, 4-fold larger or more, 4.5-fold larger or more and including where the bore size of the first needle is 5-fold larger or more than the bore size of the second needle. In certain cases, the bore size of the first needle is 16-gauge or larger, such as 15-gauge or larger, such as 14-gauge or larger, such as 13-gauge or larger and including 12-gauge or larger, and may range from 16-gauge to 12-gauge, such as 16-gauge to 13-gauge or 15-gauge to 14-gauge, and the bore size of the second needle is 18-gauge or larger, such as 17-gauge or larger, such as 16-gauge or larger, such as 15-gauge or larger, such as 14-gauge or larger, such as 13-gauge or larger and including 12-gauge or larger, and may range from 18-gauge to 12-gauge, such as 17-gauge to 13-gauge or 15-gauge to 14-gauge. In certain instances, the length of the first needle is shorter than the length of the second needle. For example, the length of the first needle may be 5% shorter or more than the length of the second needle, 10% shorter or more, 15% shorter or more, 20% shorter or more, 30% shorter or more, 40% shorter or more, 50% shorter or more, 60% shorter or more, 70% shorter or more, 80% shorter or more, 90% shorter or more, 95% shorter or more, 99% shorter or more, including 1.5-fold shorter or more, 2-fold shorter or more, 2.5 shorter or more, 3-fold shorter or more, 3.5-fold shorter or more, 4-fold shorter or more, 4.5-fold shorter or more and including where the length of the first needle is 5-fold shorter or more than the length of the second needle. In certain cases, the length of the first needle is from 0.5 inches to 2 inches, such as from 0.6 inches to 1.9 inches, such as from 0.7 inches to 1.8 inches, such as from 0.8 inches to 1.7 inches, such as from 0.9 inches to 1.6 inches and including where the length of the first needle is from 1 inch to 1.5 inches. In certain cases, the length of the first needle is 1.5 inches long. In some cases, the length of the second needle is from 2 inches to 4 inches, such as from 2.1 inches to 3.9 inches, such as from 2.2 inches to 3.8 inches, such as from 2.3 inches to 3.7 inches, such as from 2.4 inches to 3.6 inches and including from 2.5 inches to 3.5 inches. In certain cases, the length of the second needle is 3.0 inches long. In certain instances, methods include drawing up the active agent composition (e.g., bupivacaine composition containing bupivacaine, sucrose acetate isobutyrate and benzyl alcohol) with a needle having a length of 1.5 inches and administering the composition to the subject with a needle having a length of 3 inches. In certain instances, methods include drawing up the active agent composition with a 16-gauge, 1.5-inch needle and administering the composition to the subject with a 18-gauge, 3-inch needle.

In practicing the subject methods, an amount of the active agent is drawn into the syringe depending on the desired amount of active agent to be delivered to the subject, where in some cases the amounts drawn up into the syringe with the first needle is 0.1 mL or more, such as 0.5 mL or more, such as 1 mL or more, such as 2 mL or more, such as 3 mL or more, such as 4 mL or more, such as 5 mL or more, such as 6 mL or more, such as 7 mL or more, such as 8 mL or more, such as 9 mL or more and including 10 mL or more, and may range from 1 mL to 20 mL, such as 2 mL to 10 mL or 4 mL to 6 mL. Depending on the amount of active agent composition (e.g., bupivacaine composition containing bupivacaine, sucrose acetate isobutyrate and benzyl alcohol), the size of the syringe used may be a 1 mL syringe or larger, such as a 2 mL syringe, such as a 3 mL syringe, such as a 4 mL syringe, such as a 5 mL syringe, such as a 6 mL syringe, such as a 7 mL syringe, such as an 8 mL syringe, such as a 9 mL syringe and including using a 10 mL syringe or larger, and may range from 1 mL syringe to 10 mL syringe, such as 2 mL syringe to 8 mL syringe or 4 mL syringe to 6 mL syringe.

In some cases, methods include drawing up the active agent composition into a syringe with a 16-gauge or larger bore needle and administering the active agent composition to the subject with an 18-gauge or larger bore needle. In certain cases, the composition is a bupivacaine composition (e.g., containing bupivacaine, sucrose acetate isobutyrate and benzyl alcohol) and methods include drawing up 5 mL of a bupivacaine composition into a 5 mL syringe using a 16-gauge or larger bore needle to fill the syringe, the bupivacaine composition comprising bupivacaine free base or salt thereof, optionally the bupivacaine composition further comprises sucrose acetate isobutyrate and benzyl alcohol; discarding the 16-gauge or larger bore needle; and administering the 5 mL of the bupivacaine composition into the subacromial space of the subject using an 18-gauge or larger bore needle to produce post-surgical analgesia.

In some cases, methods include administering an active agent composition (e.g., bupivacaine composition containing bupivacaine, sucrose acetate isobutyrate and benzyl alcohol) into the subacromial space. In some instances, the administering occurs at the end of arthroscopic shoulder surgery. In some instances, the subject method does not include epidural administration of a bupivacaine composition. In some instances, the subject method does not include intravascular administration of a bupivacaine composition. In some instances, the subject method does not include intra-articular administration of a bupivacaine composition. In certain instances, the subject method does not include administration of a bupivacaine composition into the glenohumeral intra-articular space of the subject.

In some instances, methods include arthroscopically visualizing the subacromial space prior to administering the bupivacaine composition. In some instance, methods include confirming proper placement of the needle tip in the subacromial space before administering the bupivacaine composition. In some cases, confirming proper placement of the needle tip includes arthroscopic visualization to confirm placement of the needle tip in the subacromial space before administering the bupivacaine composition. For example, in some instances the bupivacaine composition is arthroscopically administered to the subject in a manner sufficient to avoid the glenohumeral intra-articular space.

In some instances, the administering occurs at the end of arthroscopic shoulder surgery. In some cases, the composition is administered into the subacromial space at the end of arthroscopic shoulder surgery. In one example, the composition is administered as a single injection into the subacromial space. The term “single injection” is used in its convention sense to refer to a single administrative procedure of injecting the composition. In other examples, the composition is administered as multiple injections into the subacromial space, such as at predetermined time intervals. In one example, the administering includes inserting an 18-gauge or larger bore needle into the subject through an arthroscopic port to reach the subacromial space of the subject. In another example, the administering includes inserting an 18-gauge or larger bore needle into the subject through intact skin to reach the subacromial space of the subject. In some cases, the administering occurs at a facility comprising trained personnel and equipment for treating subjects who show evidence of neurological or cardiac toxicity.

In some cases, a 16G needle is used to draw up the composition into a syringe before administration. Upon completion of the shoulder surgery, a single dose of 5.0 ml (660 mg bupivacaine) may be deposited into subacromial space through one of the arthroscopic portals. Alternatively, the dose may be administered through intact skin.

In some cases, 5.0 mL of composition is drawn up from a vial into a syringe with a large bore needle (e.g., 16 gauge or larger). After completion of surgery and prior to closure of arthroscopic portals, a 16-gauge or larger needle attached to the prepared syringe may be guided into one of the portals for administration of the composition into the subacromial space. Alternatively, the needle may be guided through intact skin into the subacromial space. The location of the needle tip may be verified by the scope prior to removal of the scope to ensure that the needle tip is placed in the subacromial space, thus eliminating the risk of inadvertent intravascular injection or a misplaced deposition of the drug. The use of irrigation fluids may be stopped, and the portals may then be sutured except the one portal containing the 16-gauge needle. Vital signs (BP, HR, respiratory rate, and temperature) may be measured prior to administration. The entire dose (e.g., 5.0 mL) of composition may be administered through the placed needle into the subacromial space. Vital signs may be measured immediately following administration.

In some cases, the subject methods and compositions provide for a reduced risk of infection, such as where the risk of post-surgical infection is reduced by 5% or more, such as by 10% or more, such as by 15% or more, such as by 20% or more, such as by 25% or more, such as by 50% or more, such as by 75% or more, such as by 90% or more and including reducing the risk of post-surgical infection by 99% or more. In some instances, the subject methods and compositions reduce the need for follow-up administration of an analgesic, such as a post-surgical analgesic. In certain instances, the need for follow-up administration is reduced by 5% or more, such as by 10% or more, such as by 15% or more, such as by 20% or more, such as by 25% or more, such as by 50% or more, such as by 75% or more, such as by 90% or more and including reducing the need for follow-up administration of analgesic by 99% or more. Further, the subject methods may reduce the number of follow-up visits to a health care provider by 1 visit or more, such as 2 visits or more, such as 3 visits or more, such as 4 visits or more and including by 5 visits to a health care provider or more.

In some cases, the active agent (e.g., bupivacaine) is administered to the subject in an amount that persists in the plasma of the subject for not more than 168 hours after the administering. In some cases, the method provides for a maximum plasma concentration (C_(max)) of the active agent of not more than 3500 ng/mL, such as not more than 3400 ng/mL, such as not more than 3300 ng/mL, such as not more than 3200 ng/mL, such as not more than 3100 ng/mL, such as not more than 3000 ng/mL, such as not more than 2900 ng/mL, such as not more than 2800 ng/mL, such as not more than 2700 ng/mL, such as not more than 2600 ng/mL and including not more than 2500 ng/mL. For example, the subject methods according to certain cases provide for a maximum bupivacaine plasma concentration of not more than 2850 ng/mL. In certain cases, the administered active agent provides a maximum plasma concentration of from 100 ng/mL to 2000 ng/mL, such as from 150 ng/mL to 1950 ng/mL, such as from 200 ng/mL to 1900 ng/mL, such as from 250 ng/mL to 1850 ng/mL, such as from 300 ng/mL to 1800 ng/mL, such as from 350 ng/mL to 1750 ng/mL, such as from 400 ng/mL to 1700 ng/mL. For example, methods according to certain cases provide for a maximum bupivacaine plasma concentration of from 200 ng/mL to 1500 ng/mL.

In some cases, the method provides for a maximum plasma concentration of the administered active agent at a time (T_(max)) ranging from 1 hour to 24 hours, such as from 2 hours to 23 hours, such as from 3 hours to 22 hours, such as from 4 hours to 21 hours, such as from 5 hours to 20 hours, such as from 6 hours to 19 hours, such as from 7 hours to 18 hours and including from 8 hours to 15 hours. In certain cases, methods provide for a maximum bupivacaine plasma concentration at a time ranging from 6 hours to 9 hours.

In some cases, the method provides for a mean half-life of the active agent of from 5 hours to 40 hours, such as from 6 hours to 39 hours, such as from 7 hours to 38 hours, such as from 8 hours to 37 hours, such as from 9 hours to 36 hours and including from 10 hours to 35 hours. In certain cases, methods provide for a mean bupivacaine half-life of from 10 hours to 35 hours, such as from 16.4 hours to 26.1 hours and including from 17 hours to 35 hours.

In some cases, the method provides for a mean active agent AUC (0-t) ranging from 5000 h*ng/mL to 65,000 h*ng/mL, such as from 6000 h*ng/mL to 60,000 h*ng/mL, such as from 7000 h*ng/mL to 55,000 h*ng/mL, such as from 8000 h*ng/mL to 50,000 h*ng/mL, such as from 9000 h*ng/mL to 45,000 h*ng/mL and including from 10,000 h*ng/mL to 40,000 h*ng/mL. In certain cases, the method provides for a mean bupivacaine AUC (0-t) ranging from 7000 h*ng/mL to 55,000 h*ng/mL, such as 20,000 h*ng/mL to 55,000 h*ng/mL. In cases, the time (t) may range from 72 hours to 192 hours, such as from 76 hours to 188 hours, such as from 80 hours to 184 hours, such as from 84 hours to 180 hours, such as from 88 hours to 176 hours, such as from 92 hours to 172 hours and including from 96 hours to 168 hours. In some cases, methods provide for a mean active agent AUC (0-96 hours) ranging from 5000 h*ng/mL to 65,000 h*ng/mL, such as from 6000 h*ng/mL to 60,000 h*ng/mL, such as from 7000 h*ng/mL to 55,000 h*ng/mL, such as from 8000 h*ng/mL to 50,000 h*ng/mL, such as from 9000 h*ng/mL to 45,000 h*ng/mL and including from 10,000 h*ng/mL to 40,000 h*ng/mL. In some instances, the method provides for a mean bupivacaine AUC (0-96 hours) ranging from 7000 h*ng/mL to 55,000 h*ng/mL, such as 20,000 h*ng/mL to 55,000 h*ng/mL. In some cases, methods provide for a mean active agent AUC (0-168 hours) ranging from 5000 h*ng/mL to 65,000 h*ng/mL, such as from 6000 h*ng/mL to 60,000 h*ng/mL, such as from 7000 h*ng/mL to 55,000 h*ng/mL, such as from 8000 h*ng/mL to 50,000 h*ng/mL, such as from 9000 h*ng/mL to 45,000 h*ng/mL and including from 10,000 h*ng/mL to 40,000 h*ng/mL. In some instances, the method provides for a mean bupivacaine AUC (0-168 hours) ranging from 7000 h*ng/mL to 55,000 h*ng/mL, such as 20,000 h*ng/mL to 55,000 h*ng/mL.

In some cases, the active agent administered persists in the plasma of the subject for not more than 168 hours after administration. For example, the active agent administered according to methods described herein persists for not more than 164 hours, such as not more than 160 hours, such as not more than 156 hours, such as not more than 152 hours, such as not more than 148 hours, such as not more than 144 hours, such as not more than 120 hours, such as not more than 96 hours. In certain cases the active agent is bupivacaine (e.g., from administering a bupivacaine composition that includes bupivacaine, sucrose acetate isobutyrate and benzyl alcohol) and bupivacaine persists in the plasma of the subject for not more than 168 hours, such as not more than 164 hours, such as not More than 160 hours, such as not more than 156 hours, such as not more than 152 hours, such as not more than 148 hours, such as not more than 144 hours, such as not more than 120 hours, such as not more than 96 hours.

In certain cases, where the composition administered to the subject is a bupivacaine composition containing bupivacaine, sucrose acetate isobutyrate and benzyl alcohol, the benzyl alcohol persists in the plasma of the subject for not more than 12 hours after administering the composition to the subject, such as not more than 11 hours, such as not more than 10 hours, such as not more than 9 hours, such as not more than 8 hours, such as not more than 7 hours, such as not more than 6 hours, such as not more than 5 hours and including not more than 4 hours.

In some cases, methods further include monitoring of the subject after administering an active agent composition described herein. In some instances, methods include monitoring cardiovascular vital signs of the subject after administering the active agent composition (e.g., after administering a bupivacaine composition that contains bupivacaine, sucrose acetate isobutyrate and benzyl alcohol). In some instances, methods include monitoring respiratory vital signs of the subject after the administering. In some instances, methods include monitoring state of consciousness of the subject after the administering. In some instances, methods include monitoring the subject for central nervous system reactions after the administering. In some instances, methods include monitoring the subject for cardiovascular reactions after the administering. In some instances, methods include monitoring the subject for allergic reactions after the administering. In some instances, methods include monitoring the subject for methemoglobinemia after the administering. In certain instances, the subject is identified as being at risk for developing methemoglobinemia. In certain instances, the subject is diagnosed as having a glucose-6-phosphate dehydrogenase deficiency. In some instances, the subject is diagnosed as having cardiac or pulmonary compromise. In certain cases, methods further include observing the subject for one or more symptoms of methemoglobinemia, such as a symptom selected from the group of cyanotic skin discoloration, discoloration of blood, seizure, coma, and heart arrythmia.

In some cases, methods include informing the subject of potential effects or physiological reaction that may occur in response to administration of the subject compositions. For example, methods may further include informing the subject that bupivacaine-containing products can cause temporary loss of sensation or motor activity in the area of infiltration. In other instances, methods may further include informing the subject of adverse reactions listed in a package insert for the bupivacaine composition.

In certain cases, methods include identifying the subject as being a subject having potential risk from adverse effects from administering the composition. In one example, methods may include informing the subject of adverse reactions listed in a package insert for the bupivacaine composition. In another example, methods may include informing the subject that bupivacaine-containing products can cause temporary loss of sensation or motor activity in the area of infiltration. In some instances, methods further include identifying the subject to be pregnant and advising the subject of potential risks to the fetus prior to the administering. In some instances, methods include determining whether the subject has a history of hypersensitivity or adverse reaction to the composition or one or more components of the compositions. In some cases, the subject does not have a history of hypersensitivity to any amide local anesthetic. In some cases, the subject does not have a history of anaphylactic reactions to any amide local anesthetic. In some cases, the subject does not have a history of serious skin reactions to any amide local anesthetic. In some cases, the subject does not have a history of hypersensitivity to sucrose acetate isobutyrate. In some cases, the subject does not have a history of anaphylactic reactions to sucrose acetate isobutyrate. In some cases, the subject does not have a history of serious skin reactions to sucrose acetate isobutyrate. In some cases, the subject does not have a history of hypersensitivity to benzyl alcohol. In some cases, the subject does not have a history of anaphylactic reactions to benzyl alcohol. In some cases, the subject does not have a history of serious skin reactions to benzyl alcohol.

In some cases, methods further include monitoring of the subject after administering an active agent composition described herein. In certain cases, methods include monitoring the site of administration of the composition. In one case, the site of administration is monitored for leakage of the composition from the subject. In certain instances, the method does not comprise bupivacaine composition leakage from the subject after the administering. In some cases, the method includes monitoring the site of administration for bruising or inflammation.

In some cases, methods include monitoring cardiovascular vital signs of the subject after administering the active agent composition (e.g., after administering a bupivacaine composition that contains bupivacaine, sucrose acetate isobutyrate, and benzyl alcohol). In some instances, methods include monitoring respiratory vital signs of the subject after the administering. In some instances, methods include monitoring state of consciousness of the subject after the administering. In some instances, methods include monitoring the subject for central nervous system reactions after the administering. In some instances, methods include monitoring the subject for cardiovascular reactions after the administering. In some instances, methods include monitoring the subject for allergic reactions after the administering. In some instances, methods include monitoring the subject for methemoglobinemia after the administering. In certain instances, the subject is identified as being at risk for developing methemoglobinemia. In certain instances, the subject is diagnosed as having a glucose-6-phosphate dehydrogenase deficiency. In some instances, the subject is diagnosed as having cardiac or pulmonary compromise. In certain cases, methods further include observing the subject for one or more symptoms of methemoglobinemia, such as a symptom selected from the group of cyanotic skin discoloration, discoloration of blood, seizure, coma and heart arrythmia.

In some cases, methods further include administering in response to a request by the subject an opioid analgesic in an amount sufficient to treat post-surgical pain in the subject from 0 hours to 72 hours after administering the bupivacaine composition. In some instances, the opioid analgesic is morphine. In some cases, methods include intravenously administering the opioid analgesic (e.g., 2 mg of morphine) to the subject. In some cases, methods include orally administering the opioid analgesic (e.g., 10 mg of morphine) to the subject.

In certain cases, methods described herein are sufficient to reduce the amount of concurrent therapy needed by the subject, such as for example to reduce pain. By “concurrent therapy” is meant administration to the subject another therapeutic composition such that the therapeutic effect of the combination of the substances is achieved. For example, concurrent therapy may be achieved by administering a bupivacaine composition according to the subject methods and administering a pharmaceutical composition having at least one other agent, such as pain treatment compositions. In certain cases, methods include co-administering one or more opioids to the subject. The term “opioid” is used herein in its conventional sense to refer to the naturally occurring or synthetic chemical substances that exert pharmacological action by interaction at opioid receptors (i.e., μ, κ and δ opioid receptors). In certain cases opioids are biosynthetic benzylisoquinoline alkaloids and may be opioid receptor agonists, antagonists and inverse agonists.

Depending on the second therapeutic agent being administered and the condition indicated, concurrent administration of the bupivacaine composition with a second therapeutic agent may reduce the required administration amount of the second therapeutic agent. For example, concurrent administration of the bupivacaine composition may reduce the amount of opioid or other analgesic required to effectively treat or manage pain (e.g., opioid sparing). In some cases, the subject methods may reduce the required administration amount of opioids by 10% or more, such as 25% or more, such as 35% or more and including reducing the required administration amount of second therapeutic agent by 50% or more. For example, the subject methods may reduce the required administration amount of post-surgical opioids (e.g., administered within 14 days of surgery, such as within 12 days, within 10 days, within 8 days, within 7 days, within 6 days, within 5 days, within 4 days, within 3 days, within 2 days, or within 1 day of surgery) by 10% or more, such as 25% or more, such as 35% or more and including reducing the required administration amount of second therapeutic agent by 50% or more.

The type of opioid co-administered to the subject in methods according to these cases may vary, including but not limited to codeine, morphine, oripavine, pseudomorphine, thebaine, 14-dydroxymorphine, 2,4-dinitrophenylmorphine, 6-methyldihydromorphine, 6-methylenedihydrodesoxymorphine, 6-acetyldihydromorphine, azidomorphine, chlornaltrexamine, chloroxymorphamine, desomorphine (dihydrodesoxymorphine), dihydromorphine, ethyldihydromorphine, hydromorphinol, methyldesorphine, N-phenethylnormorphine, RAM-378, 6-nicotinoyldihydromorphine, acetylpropionylmorphine, diacetyldihydromorphine (dihydroheroin, acetylmorphinol), dibutyrylmorphine, dibenzoylmorphine, diformylmorphine, dipropanoylmorphine, heroin (diacetylmorphine), nicomorphine, 6-monoacetylcodeine, benzylmorphine, codeine methylbromide, desocodeine, dimethylmorphine (6-O-methylcodeine), ethyldihydromorphine, methyldihydromorphine (dihydroheterocodeine), ethylmorphine (dionine), heterocodeine, isocodeine, pholcodine (morpholinylethylmorphine), myrophine, nalodeine (N-allyl-norcodeine), transisocodeine, 14-cinnamoyloxycodeinone, 14-ethoxymetopon, 14-methoxymetopon, 14-phenylpropoxymetopon, 7-spiroindanyloxymorphone, 8,14-dihydroxydihydromorphinone, acetylcodone, acetylmorphone, α-hydrocodol, bromoisopropropyldihydromorphinone, codeinone, codorphone, codol, codoxime, IBNtxA, acetyldihydrocodeinone, dihydrocodeinone enol acetate, hydrocodone, hydromorphone, hydroxycodeine, methyldihydromorphinone, morphenol, morphinone, morphol, N-phenethyl-14-ethoxymetopon, oxycodone, oxymorphol, oxymorphone, pentamorphone, semorphone, α-chlorocodide, β-chlorocodide, α-chloromorphide, bromocodide, bromomorphide, chlorodihydrocodide, chloromorphide, codide, 14-hydroxydihydrocodeine, acetyldihydrocodeine, dihydrocodeine, dihydrodesoxycodeine, dihydroisocodeine, nicocodeine, nicodicodeine, 1-nitrocodeine, codeine-N-oxide, morphine-N-oxide, oxymorphazone, 1-bromocodeine, 1-chlorocodeine, 1-iodomorphine, codeine-N-oxide, heroin-7,8-oxide, morphine-6-glucuronide, 6-monoacetylmorphine, morphine-N-oxide, naltrexol, norcodeine, normorphine, among other opioids.

In certain cases, administering a bupivacaine composition as described herein when co-administered with an opioid may reduce the amount of opioid required to effectively treat or manage pain. In some instances, methods of the present disclosure reduce the amount of co-administered opioid needed to manage pain by 1% or more by weight, such as by 2% or more by weight, such as by 3% or more by weight, such as by 5% or more by weight, such as by 10% or more by weight, such as by 15% or more by weight, such as by 25% or more by weight and including reducing the amount of co-administered opioid needed to manage pain by 50% or more by weight. In other words, the amount of opioid needed to manage the pain is reduced by 1% or more by weight as compared to the amount of opioid alone that is needed to manage pain, such as by 2% or more by weight, such as by 3% or more by weight, such as by 5% or more by weight, such as by 10% or more by weight, such as by 15% or more by weight, such as by 25% or more by weight and including where the amount of opioid needed to manage pain is reduced by 50% or more by weight as compared to the amount of opioid alone that is needed to manage the pain. For example, the amount of co-administered opioid needed to manage pain (e.g., administered within 14 days of surgery, such as within 12 days, within 10 days, within 8 days, within 7 days, within 6 days, within 5 days, within 4 days, within 3 days, within 2 days, or within 1 day of surgery) may be reduced by 1% or more by weight, such as by 2% or more by weight, such as by 3% or more by weight, such as by 5% or more by weight, such as by 10% or more by weight, such as by 15% or more by weight, such as by 25% or more by weight and including reducing the amount of co-administered opioid needed to manage pain by 50% or more by weight. In certain cases, the subject methods are sufficient to altogether eliminate the need for administering opioids to the subject to manage post-surgical pain. In certain instances, the subject method are sufficient to altogether eliminate administering opioids in producing post-surgical analgesia.

In some cases, a rescue analgesic is administered to the subject to manage post-surgical pain. In certain cases, the rescue analgesic is an opioid analgesic. The term “rescue analgesic” is used herein in it conventional sense to refer to an analgesic administered to the subject in response to pain experienced by the subject which is determined to require analgesic intervention. In some instances, the rescue analgesic is requested by the subject experiencing the pain. In other instances, the rescue analgesic is administered to the subject based on an evaluation by a qualified health care professional. In other instances, the rescue analgesic is administered as part of a predetermined time interval of analgesic intervention.

In some instances, the rescue analgesic administered to the subject is an opioid, such as those described above. The amount of rescue analgesic will depend on the type of analgesic (e.g., opioid or non-opioid) and may range from 1 mg to 15 mg, such as from 2 mg to 14 mg, such as from 3 mg to 13 mg, such as from 4 mg to 12 mg and including from 5 mg to 10 mg. One or more doses of rescue analgesic may be administered to the subject from 0 hours to 72 hours after administering the bupivacaine compositions described herein, such as where the subject is administered rescue analgesic 2 or more times from 0 hours to 72 hours after administering the bupivacaine composition, such as 3 or more times, such as 4 or more times and including 5 or more times. In certain cases, the amount of rescue analgesic administered to the subject within 72 hours after administering the active agent composition (e.g., bupivacaine composition as described above) is less than 12 mg based on an IV morphine equivalent dose, such as less than 11 mg, such as less than 10 mg, such as less than 9 mg, such as less than 8 mg, such as less than 7 mg, such as less than 6 mg, such as less than 5 mg and including less than 4 mg. In certain cases, the amount of rescue analgesic administered to the subject is an amount that is less than the mean amount administered to an otherwise identical subjects that were not administered the bupivacaine composition (e.g., a bupivacaine composition containing bupivacaine, sucrose acetate isobutyrate and benzyl alcohol).

In some cases, methods include producing analgesia in a subject. Analgesia, such as post-surgical analgesia, may be characterized by assessing pain intensity. For instance, the subject may assess pain intensity using a Numerical Rating Score (NRS) scale of 0-10, where zero (0)=no pain, and ten=(10) pain as intense as imaginable. The pateints may be asked to assess the pain intensity verbally or visually by pointing to where their pain lies on a horizontal line, e.g., 10 cm horizontal line. Pain intensity on movement after subacromial decompression surgery may be assessed by obtaining an NRS score after raising the shoulder (90 degrees) to elicit shoulder pain. The methods of the present disclosure may produce post-surgical analgesia, e.g., relative to placebo control, by showing an improvement in pain intensity after surgery, e.g., 1 day, 2 days, or 3 days after surgery. For instance, pain intensity may be rated by the patients using a 0 to 10 numerical rating scale (NRS) at multiple time points up to 72 hours after surgery.

In some cases, methods do not comprise obstetrical paracervical block anesthesia. In some cases, the method does not comprise a nerve block. In some cases, the method does not comprise a regional nerve block. In some cases, the method does not comprise neuraxial nerve blockade. In some cases, the method does not comprise peripheral nerve blockade. In some cases, the method does not comprise pre-incisional or pre-procedural locoregional anesthetic techniques that require deep and complete sensory block in the area of administration.

In some cases, the active agent composition (e.g., bupivacaine composition) is stored for a period of time prior to being drawn up in to the syringe. For example, the active agent composition may be stored for 30 minutes or longer, such as 1 hour or longer, such as 2 hours or longer, such as 4 hours or longer, such as 8 hours or longer, such as 12 hours or longer, such as 16 hours or longer, such as 20 hours or longer, such as 1 day or longer, such as 2 days or longer, such as 3 days or longer, such as 4 days or longer, such as 5 days or longer, such as 6 days or longer, such as 1 week or longer, such as 2 weeks or longer, such as 3 weeks or longer, such as 1 month or longer, such as 2 months or longer, such as 3 months or longer, such as 6 months or longer and including storing the composition for 1 year or longer. The active agent composition may be stored to the period of time at temperatures ranging from 5° C. to 50° C., such as from 10° C. to 45° C., such as from 15° C. to 40° C., such as from 20° C. to 35° C. and including from 25° C. to 30° C. The active agent composition may also be stored at a relative humidity that ranges from 40% RH to 80% RH, such as from 45% RH to 75% RH, such as from 50% RH to 70% RH, such as from 55% RH to 65% RH and including from 50% RH to 60% RH prior to being drawn up in to the syringe. In some instances, the active agent composition is a bupivacaine composition that is stored at a temperature from 15° C. to 30° C. prior to being drawn up in to the syringe. In some instances, the active agent composition is a bupivacaine composition that is stored at a relative humidity of 60% RH. In certain instances, the active agent composition is a bupivacaine composition that is stored at a temperature from 15° C. to 30° C. and at 60% RH prior to being drawn up in to the syringe.

The active agent composition may be stored in vials, such as single-dose vials. In some cases, the glass vial is pyrex glass, a boron silica glass or other type of glass. In certain instances, the glass vial is formed from a glass material which does not contain iron. In some cases, the vial is a clear vial, such as a clear-glass vial. The term “clear” is used herein in its conventional sense to refer to the relative lack of opacity of the vial to certain wavelengths of light. For example, the vial may lack opacity to visible wavelengths of light such that the vial appears “clear” when visualized with the naked eye. In some cases, the vial lacks opacity to ultraviolet light. In some cases, the vial lacks opacity to infrared light.

Vials of the active agent composition (e.g., bupivacaine composition containing bupivacaine, sucrose acetate isobutyrate and benzyl alcohol) may contain 0.1 mL or more of the active agent composition, such as 0.5 mL or more, such as 1 mL or more, such as 2 mL or more, such as 3 mL or more, such as 4 mL or more, such as 5 mL or more, such as 6 mL or more, such as 7 mL or more, such as 8 mL or more, such as 9 mL or more and including 10 mL or more. For example, vials of interest may include 5 mL of bupivacaine composition. Vials may be single dose or multi-dose vials. In one case, vials used to practice the subject methods are single dose vials. In a second case, vials used to practice the subject methods are multi-dose vials (e.g., 2-dose vials, 3-dose vials, 4-dose vials, 5-dose vials, including 10-dose or more vials)

In certain cases, the vial is stored in a carton or other type of packaging container. For example, the carton may be a cardboard, plastic or other type of carton. In some instances, the carton is opaque to visible light such that storage in the carton prevents the exposure of the vials to light. In some instances, the carton is a packaging container that is sealed to prevent exposure of the vials to moisture. The carton may include any number of vials depending on the size of the carton and the vials, where in certain instances, the carton contains 2 vials or more, such as 3 vials or more, such as 4 vials or more, such as 5 vials or more, such as 6 vials or more, such as 7 vials or more, such as 8 vials or more, such as 9 vials or more, such as 10 vials or more, such as 15 vials or more, such as 20 vials or more, such as 30 vials or more, such as 40 vials or more, such as 50 vials or more, such as 60 vials or more, such as 70 vials or more, such as 80 vials or more, such as 90 vials or more and including 100 vials or more. In certain cases, the carton is a packaging container that is a 2-unit carton (i.e., contains 2-vials), 5-unit carton, 10-unit carton, 12-unit carton, 15-unit carton, 16-unit carton, 20-unit carton, 24-unit carton, 28-unit carton, 30-unit carton, 32-unit carton, 50-unit carton, 64-unit carton or a 100-unit carton.

The vials may be stored in an upright position or an inverted position. In certain instances, one or more vials of active agent composition (e.g., bupivacaine composition) is stored in a carton in an upright position. In other instances, one or more vials of active agent composition (e.g., bupivacaine composition) are stored in a carton in an inverted position.

As described in detail above, the present disclosure provides for methods of producing analgesia in a subject by administering an amount of an active agent to the subject. Suitable pharmaceutical agents include polysaccharides, DNA and other polynucleotides, antisense oligonucleotides, antigens, antibodies, vaccines, vitamins, enzymes, proteins, naturally occurring or bioengineered substances, and the like, anti-infectives (including antibiotics, antivirals, fungicides, scabicides or pediculicides), antiseptics (e.g., benzalkonium chloride, benzethonium chloride, chlorhexidine gluconate, mafenide acetate, methylbenzethonium chloride, nitrofurazone, nitromersol and the like), steroids (e.g., estrogens, progestins, androgens, adrenocorticoids and the like), opioids (e.g., buprenorphine, butorphanol, dezocine, meptazinol, nalbuphine, oxymorphone and pentazocine), therapeutic polypeptides (e.g., insulin, erythropoietin, morphogenic proteins such as bone morphogenic protein, and the like), analgesics and anti-inflammatory agents (e.g., aspirin, ibuprofen, naproxen, ketorolac, COX-1 inhibitors, COX-2 inhibitors and the like), antipsychotic agents (for example, phenothiazines including chlorpromazine, triflupromazine, mesoridazine, piperacetazine and thioridazine; thioxanthenes including chlorprothixene and the like), antiangiogenic agents (e.g., combresiatin, contortrostatin, anti-VEGF and the like), anti-anxiety agents (for example, benzodiazepines including diazepam, alprazolam, clonazepam, oxazepam; and barbiturates), antidepressants (including tricyclic antidepressants and monoamine oxidase inhibitors including imipramine, amitriptyline, doxepin, nortriptyline, amoxapine, tranylcypromine, phenelzine and the like), stimulants (for example, methylphenidate, doxapram, nikethamide and the like), narcotics (for example, buprenorphine, morphine, meperidine, codeine and the like), analgesic-antipyretics and anti-inflammatory agents (for example, aspirin, ibuprofen, naproxen and the like), local anesthetics (e.g., the amide- or anilide-type local anesthetics such as bupivacaine, levobupivacaine, dibucaine, mepivacaine, procaine, lidocaine, tetracaine, ropivacaine, and the like), fertility control agents, chemotherapeutic and anti-neoplastic agents (for example, mechlorethamine, cyclophosphamide, 5-fluorouracil, thioguanine, carmustine, lomustine, melphalan, chlorambucil, streptozocin, methotrexate, vincristine, bleomycin, vinblastine, vindesine, dactinomycin, daunorubicin, doxorubicin, tamoxifen and the like), cardiovascular and anti-hypertensive agents (for example, procainamide, amyl nitrite, nitroglycerin, propranolol, metoprolol, prazosin, phentolamine, trimethaphan, captopril, enalapril and the like), drugs for the therapy of pulmonary disorders, anti-epilepsy agents (for example, phenyloin, ethotoin and the like), anti-hidrotics, keratoplastic agents, pigmentation agents or emollients, antiemetic agents (such as ondansetron, granisetron, tropisetron, metoclopramide, domperidone, scopolamine, palonosetron, and the like). The composition of the present application may also be applied to other locally acting active agents, such as astringents, antiperspirants, irritants, rubefacients, vesicants, sclerosing agents, caustics, escharotics, keratolytic agents, sunscreens and a variety of dermatologics including hypopigmenting and antipruritic agents.

In some cases, the active pharmaceutical agent is present in an amount ranging from 0.5 to 20 percent, 1 to 8 percent, 2 to 6 percent, 2 to 5 percent, or 1 to 5 percent by weight of the composition.

As used herein, the term “anesthetic” intends any agent that provides reversible local numbness, pain relief, blocks impulse conduction along nerve axions and other excitable membranes, such as a regional blockage of nociceptive pathways (afferent and/or efferent), analgesia, and/or anesthesia. See, e.g., Strichartz, G. R. (Ed.) Local Anesthetics, Handbook of Experimental Pharmacology, vol. 81, Springer, Berlin/New York, (1987). The term also includes any agent which, when locally administered provides localized (regional) full or partial inhibition of sensory perception and/or motor function. Examples of commonly used agents suitable for use as anesthetics include, but are not limited to ambucaine, amolanone, amylcaine, benoxinate, benzyl alcohol, benzocaine, betoxycaine, biphenamine, bupivacaine, butacaine, butamben, butanilicaine, butethamine, butoxycaine, carticaine, chloroprocaine, cocaethylene, cocaine, cyclomethycaine, dibucaine, dimethisoquin, dimethocaine, diperodon, dyclonine, ecogonidine, ecogonine, etidocaine, euprocin, fenalcomine, formocaine, hexylcaine, hydroxyteteracaine, isobuanine, isobutyl p-aminobenzoate, leucinocaine, levobupivacaine, levoxadrol, lidocaine, mepivacaine, meprylcaine, metabutoxycaine, methyl chloride, myrtecaine, naepaine, octacaine, orthocaine, oxethazaine, parenthoxycaine, phenacaine, phenol, piperocaine, piridocaine, polidocanol, pramoxine, prilocaine, procaine, propanocaine, proparacaine, propipocaine, propoxycaine, pseudococaine, pyrrocaine, ropivacaine, salicyl alcohol, tetracaine, tolycaine, trimecaine, xylocaine, zolamine, anesthetically active derivatives, analogs and any pharmaceutically acceptable salt thereof, and any mixture thereof.

The amide- and ester-type of local anesthetics are preferred for use herein. Amide-type local anesthetics are characterized by having an amide functionality, while ester-type local anesthetics contain an ester functionality. Preferred amide-type local anesthetics include lidocaine, bupivacaine, prilocaine, mepivacaine, etidocaine, ropivacaine and dibucaine. Preferred ester-type local anesthetics include tetracaine, procaine, benzocaine and chloroprocaine. In one case, the amide-type local anesthetic is selected from the group consisting of bupivacaine, ropivacaine, levobupivacaine, dibucaine, mepivacaine, procaine, lidocaine, and tetracaine. The most preferred local anesthetic is bupivacaine.

The anesthetic agent is provided in the composition in a neutral form, as a free base form, or in the form of a pharmaceutically acceptable salt. The term “pharmaceutically acceptable salt,” as used herein, intends those salts that retain the biological effectiveness and properties of neutral anesthetics and are not otherwise unacceptable for pharmaceutical use. Pharmaceutically acceptable salts include salts of acidic or basic groups, which groups may be present in the anesthetic agents. Those anesthetic agents that are basic in nature are capable of forming a wide variety of salts with various inorganic and organic acids. Pharmaceutically acceptable acid addition salts of basic anesthetics suitable for use herein are those that form non-toxic acid addition salts, i.e., salts comprising pharmacologically acceptable anions, such as the hydrochloride, hydrobromide, hydroiodide, nitrate, sulfate, bisulfate, phosphate, acid phosphate, isonicotinate, acetate, lactate, salicylate, citrate, tartrate, pantothenate, bitartrate, ascorbate, succinate, maleate, gentisinate, fumarate, gluconate, glucaronate, saccharate, formate, benzoate, glutamate, methanesulfonate, ethanesulfonate, benzenesulfonate, p-toluenesulfonate and pamoate (i.e., 1,1′-methylene-bis-(2-hydroxy-3-naphthoate)) salts. Anesthetic agents that include an amino moiety may form pharmaceutically acceptable salts with various amino acids, in addition to the acids mentioned above. Suitable base salts can be formed from bases which form non-toxic salts, for example, aluminium, calcium, lithium, magnesium, potassium, sodium, zinc and diethanolamine salts. See, e.g., Berge et al. (1977) J. Pharm. Sci. 66:1-19.

In some cases, the amount of the active agent compound (e.g., bupivacaine, bupivacaine free base, bupivacaine salt) may be present in an amount that varies and may range from 10 mg to 1000 mg, such as from 25 mg to 900 mg, such as from 50 mg to 800 mg, such as from 75 mg to 700 mg, such as from 100 mg to 600 mg and including from 250 mg to 500 mg. In certain cases, the subject compositions include the active agent in an amount from 600 mg to 700 mg, such as about 660 mg. In certain instances, compositions of interest are bupivacaine compositions and bupivacaine is present in the composition in an amount of 660 mg, such as 660 mg bupivacaine free base equivalent. The concentration of the active agent in the composition may vary, ranging from 0.1 mg/mL to 250 mg/mL, such as from 0.5 mg/mL to 225 mg/mL, such as from 1 mg/mL to 200 mg/mL, such as from 5 mg/mL to 175 mg/mL, and including from 10 mg/mL to 150 mg/mL. In certain cases, the concentration of the active agent in the subject composition is from 125 mg/mL to 150 mg/mL. In certain instances, compositions of interest are bupivacaine compositions and the concentration of bupivacaine in the composition is about 132 mg/mL bupivacaine free base equivalent.

The ability of an anesthetic agent to provide a condition of sustained local anesthesia refers to the ability of the subject agent to establish an assessable state of localized (regional) full or partial inhibition of sensory perception and/or motor function. Numerous methods and tools for making such an assessment will readily occur to the skilled artisan. With regard to non-human animal subjects, these methods include measurement of spontaneous locomotion in test rats (using, for example, commercially available equipment and software from Med Associates Inc., St. Albans, Vt.), where data can be collected on total distance traveled, ambulatory counts, stereotypy, rearing, time spent in the various motions and time spent at rest for test subjects; visualization of pin prick reaction in rats; and the rat hotplate foot withdrawal model, e.g., according to the procedure described in detail in IACUC No 9511-2199.

With regard to selection of a particular anesthetic agent, the skilled artisan will also recognize that the pharmacological properties of each candidate agent will vary, for example, with respect to onset and intensity of anesthetic effect, duration and the like. Certain agents may provide a mild anesthetic effect, having a fairly rapid onset of activity, but a short duration. Such agents can be used with the compositions in order to provide an “initial anesthetic effect,” where they are typically paired with a different anesthetic agent that provides a “sustained local anesthesia,” characterized by a more gradual onset of activity, but a stronger effect and one of longer duration. An example of an anesthetic that can be used to provide an initial anesthetic effect is benzyl alcohol. An example of an anesthetic that can be used to provide a sustained local anesthesia is bupivacaine. Still further agents that can be used to provide an initial anesthetic effect can include organic materials commonly used as solvents and/or penetration agents, such as ethanol, dimethyl sulfoxide, N-methylpyrrolidone, polyethylene glycol and certain fatty acid esters. These and other similar agents can provide a very mild initial anesthetic effect, for example, when applied they can cool or otherwise desensitize/numb a tissue site, thereby partially inhibiting sensory perception at that site. Whenever an agent is used in order to provide an initial anesthetic effect, the agent is provided in a suitable composition in an amount sufficient to provide the subject effect, and in such a way that the agent is able to be released from the composition quickly in order to provide the intended effect. Assembly of such suitable compositions (containing an agent for providing an initial anesthetic effect) is within the skill of the art when taken in combination with the guidance and teaching provided by the instant specification.

In some cases, the composition includes only a single active agent, such as a single anesthetic. In certain cases, the composition includes only bupivacaine as a single active agent. For example, the bupivacaine composition does not include any drugs (e.g., any local anesthetics) other than the bupivacaine free base or salt thereof. In certain cases, no other active agent (e.g., any other anesthetic) is administered to the subject for at least 168 hours after administering the active agent composition to the subject. For example, no other anesthetic is administered for 168 hours or more after administering the bupivacaine composition to the subject.

In some cases, the bupivacaine composition is administered to the subject in an undiluted form. In some cases, methods include not autoclaving the bupivacaine composition. Thus, in some cases, the bupivacaine composition is not autoclaved. In some cases, methods include not mixing the bupivacaine composition. In some cases, methods include not diluting the bupivacaine composition.

In certain cases, a composition is provided that includes two anesthetic agents, a first anesthetic and a second anesthetic, wherein the second anesthetic agent is a solvent for the first anesthetic agent. In these particular compositions, the second anesthetic agent is typically used to provide an initial anesthetic effect, and the first anesthetic agent is used to provide a subsequent anesthetic effect characterized by sustained local anesthesia, having an onset within 2 hours of administration to a subject without an initial burst, and a duration of at least 24 hours after administration, or even longer. In certain preferred cases, the first anesthetic agent provides the sustained local anesthesia with an onset within 1 to 2 hours of administration, and in other preferred cases, the first anesthetic agent provides the sustained local anesthesia with an onset within 30 minutes to 1 hour of administration. In certain other cases, the second anesthetic is also a solvent for the sustained release carrier system.

The concentration of the anesthetic in the composition will also depend on absorption, inactivation, and excretion rates of that particular agent, as well as other factors known to those of skill in the art. It is to be noted that dosage values will also vary with the severity of the condition to be alleviated. It is to be further understood that for any particular subject, specific dosage regimens should be adjusted over time according to the individual need and the professional judgment of the person administering or supervising the administration of the compositions, and that the concentration ranges set forth herein are exemplary only and are not intended to limit the scope or practice of the claimed composition. The composition may be administered in one dosage, or may be divided into a number of smaller doses to be administered at varying intervals of time, either sequentially or concurrently.

The anesthetic agent or agents will typically be present in the composition in the range from 0.1 to 99.5 percent by weight relative to the total weight of the composition (wt %), from 0.5 to 70 wt %, or from 1 percent to 50 wt %. However, ranges having upper endpoints as low as 40%, 30%, 20%, or 10% can be used, as can ranges having lower limits as high as 5%, 3%, or 2%. For very active anesthetic agents, the ranges may be less than 1% by weight, and possibly less than 0.0001%.

An anesthetic agent will serve as a solvent for another anesthetic agent herein when one agent is at least partially dissolved in the other solvent agent in the manufacture of the composition. In addition, the anesthetic solvent is present in the composition in an amount sufficient to provide both an initial anesthetic effect and at least partially dissolve the other anesthetic agent. In certain cases, the second anesthetic is thus present in an amount of from 95 to 1 percent by weight relative to the total weight of the composition (wt %), or in an amount of from 75 to 10 wt %, or in an amount of from 50 to 15 wt %.

A number of suitable anesthetic agents that also serve as solvents for other anesthetic agents can be used. Suitable agents include aromatic alcohols, acids and acid derivatives, and combinations thereof. A particularly preferred anesthetic agent that can be used as a solvent for an additional anesthetic is benzyl alcohol.

In some cases, the sustained release carrier systems employed in the compositions of the present disclosure are classified as non-polymeric carriers. A pharmaceutically acceptable non-polymeric carrier is typically biocompatible, and preferably biodegradable, bioerodible, or bioabsorbable. A substance is biocompatible if it and any of its degradation products present no significant, deleterious or untoward effects, nor cause substantial tissue irritation or necrosis when administered to living tissue. “Biodegradable” or “bioerodible,” used interchangeably herein, means the subject non-polymeric material will degrade or erode in vivo to form smaller chemical species, wherein such degradation can result, for example, from enzymatic, chemical, and physical processes. “Bioabsorbable” means that a given nonpolymeric material can be broken down and absorbed within an animal subject's body, for example, by a cell, tissue or the like.

In some cases, the non-polymeric carrier material is used to control release of at least one anesthetic agent from the compositions, in such a way as to provide a sustained local anesthesia having an onset within 2 hours of administration and a duration of at least 24 hours or longer. In some cases, the non-polymeric carrier material comprises HVLCM (e.g., sucrose acetate isobutyrate) present in the composition in an amount sufficient to provide sustained release of the active pharmaceutical agent from the composition, such as sustained release of about 72 hours. In some compositions, the non-polymeric carrier material is sufficient to provide either a first order sustained-release profile of the at least one anesthetic, or a pseudo-zero order release profile. Accordingly, the non-polymeric carrier will be present in the composition in an amount of from 99.5 to 1 percent by weight relative to the total weight of the composition (wt %), or in an amount of from 95 to 10 wt %, or in an amount of from 75 to 25 wt %. In some cases, the non-polymeric carrier comprises a high viscosity liquid carrier material (HVLCM), e.g., sucrose acetate isobutyrate, present at a level ranging from 30 wt % to 80 wt %, such as from 40 wt % to 70 wt %, from 50 wt % to 70 wt %, from 60 wt % to 70 wt %, from 61 wt % to 69 wt %, from 62 wt % to 68 wt %, or from 63 wt % to 67 wt %, based on weight of the composition.

Selection of a suitable non-polymeric carrier is within the general skill in the art, using the teaching and guidance provided by the instant disclosure and specification. For example, numerous pharmaceutically acceptable non-polymeric carrier systems are available to the skilled artisan to produce liquid, spray, cream, lotion, ointment, gel, slurry, oil, emulsion, microemulsion, solid, plaster, film, particle, microparticle, powder or other suitable form pharmaceutical compositions. These and other carrier systems are described, for example, in Remington's Pharmaceutical Sciences, 16^(th) Edition, 1980 and 17^(th) Edition, 1985, both published by Mack Publishing Company, Easton, Pa.

The compositions described herein may further include one or more additional components, for example pharmaceutically acceptable excipient materials that can act as dispersing agents, bulking agents, binders, carriers, stabilizers, glidants, antioxidants, pH adjusters, anti-irritants, thickening agents, rheology modifiers, emulsifiers, preservatives, and the like. The skilled artisan will appreciate that certain excipient materials can serve several of the above-referenced functions in any particular formulation. Thus, any number of suitable excipient materials can be mixed with or incorporated into the compositions to provide bulking properties, alter active agent release rates, increase or impede water uptake, control pH, provide structural support, facilitate manufacturing processes and other uses known to those skilled in the art. The term “excipient” generally refers to a substantially inert material that is nontoxic and does not interact with other components of the composition in a deleterious manner. The proportions in which a particular excipient may be present in the composition depend upon the purpose for which the excipient is provided and the identity of the excipient.

For example, suitable excipients that can also act as stabilizers for active agents include pharmaceutical grades of dextrose, sucrose, lactose, trehalose, mannitol, sorbitol, inositol, dextran, and the like. Such stabilizers may thus be a saccharide such as a monosaccharide, a disaccharide, a polysaccharide or a sugar alcohol. Other suitable excipients include starch, cellulose, sodium or calcium phosphates, calcium sulfate, citric acid, tartaric acid, glycine, and combinations thereof. Examples of hydrophobic excipients that can be added to slow hydration and dissolution kinetics include fatty acids and pharmaceutically acceptable salts thereof (e.g., magnesium stearate, steric acid, zinc stearate, palimitic acid, and sodium palitate).

It may also be useful to employ a charged lipid and/or detergent excipient in the compositions. Suitable charged lipids include, without limitation, phosphatidylcholines (lecithin), and the like. Detergents will typically be a nonionic, anionic, cationic or amphoteric surfactant. Examples of suitable surfactants include, for example, Tergitol® and Triton® surfactants (Union Carbide Chemicals and Plastics); polyoxyethylenesorbitans, e.g., TWEEN® surfactants (Atlas Chemical Industries); polysorbates; polyoxyethylene ethers, e.g., Brij; pharmaceutically acceptable fatty acid esters, e.g., lauryl sulfate and salts thereof; ampiphilic surfactants (glycerides, etc.); and like materials.

Other excipient materials can be added to alter porosity, for example, materials like sucrose, dextrose, sodium chloride, sorbitol, lactose, polyethylene glycol, mannitol, fructose, polyvinyl pyrrolidone or appropriate combinations thereof. Additionally, the anesthetic agent or agents may be dispersed with oils (e.g., sesame oil, corn oil, vegetable, soybean oil, castor oil, peanut oil), or a mixture thereof with a phospholipid (e.g., lecithin), or medium chain fatty acid triglycerides (e.g., Miglyol 812) to provide an oily suspension.

Still further excipient materials that can be incorporated into the compositions include diluents of various buffer content (e.g., Tris-HCl, acetate); pH and ionic strength altering agents; additives such as antioxidants (e.g., ascorbic acid, glutathione, sodium metabisulfite); preservatives (e.g., Thimersol, benzyl alcohol, methyl paraben, propyl paraben); and dispersing agents such as water-soluble polysaccharides (e.g., mannitol, lactose, glucose, starches), hyaluronic acid, glycine, fibrin, collagen and inorganic salts (e.g., sodium chloride).

In certain cases, the non-polymeric carrier is substantially insoluble in water or in an aqueous biological system. Exemplary such non-polymeric carrier materials include, but are not limited to: sterols such as cholesterol, stigmasterol, β-sitosterol, and estradiol; cholestery esters such as cholesteryl stearate; C₁₂-C₂₄ fatty acids such as lauric acid, myristic acid, palmitic acid, stearic acid, arachidic acid, behenic acid, and lignoceric acid; C₁₈-C₃₆ mono-, di- and triacylglycerides such as glyceryl monooleate, glyceryl monolinoleate, glyceryl monolaurate, glyceryl monodocosanoate, glyceryl monomyristate, glyceryl monodicenoate, glyceryl dipalmitate, glyceryl didocosanoate, glyceryl dimyristate, glyceryl didecenoate, glyceryl tridocosanoate, glyceryl trimyristate, glyceryl tridecenoate, glycerol tristearate and mixtures thereof; sucrose fatty acid esters such as sucrose distearate and sucrose palmitate; sorbitan fatty acid esters such as sorbitan monostearate, sorbitan monopalmitate and sorbitan tristearate; C₁₆-C₁₈ fatty alcohols such as cetyl alcohol, myristyl alcohol, stearyl alcohol, and cetostearyl alcohol; esters of fatty alcohols and fatty acids such as cetyl palmitate and cetearyl palmitate; anhydrides of fatty acids such as stearic anhydride; phospholipids including phosphatidylcholine (lecithin), phosphatidylserine, phosphatidylethanolamine, phosphatidylinositol, and lysoderivatives thereof; sphingosine and derivatives thereof; spingomyelins such as stearyl, palmitoyl, and tricosanyl spingomyelins; ceramides such as stearyl and palmitoyl ceramides; glycosphingolipids; lanolin and lanolin alcohols; and combinations and mixtures thereof. Certain preferred non-polymeric carriers include cholesterol, glyceryl monostearate, glycerol tristearate, stearic acid, stearic anhydride, glyceryl monocleate, glyceryl monolinoleate, and acetylated monoglycerides.

If one of the above-noted non-polymeric carrier materials is selected for use in a composition, it will typically be combined with a compatible and suitable organic solvent for the carrier material to form a composition having a consistency ranging from watery to viscous to a spreadable putty or paste. The consistency of the composition will vary according to factors such as the solubility of the non-polymeric carrier in the solvent, the concentration of the non-polymeric carrier, the concentration of the anesthetic agent and/or the presence of additional anesthetic agents, additives and excipients. The solubility of a non-polymeric carrier in a particular solvent will vary according to factors such as its crystallinity, hydrophilicity, ionic character and lipophilicity. Accordingly, the ionic character and the concentration of the non-polymeric carrier in the solvent can be adjusted to achieve the desired solubility. Preferred non-polymeric carrier materials are those that have low crystallinity, nonpolar characteristics, and are more hydrophobic.

Suitable organic solvents for use in the compositions are generally those that are biocompatible, pharmaceutically acceptable, and will at least partially dissolve the non-polymeric carrier. The organic solvent will further have a solubility in water ranging from miscible to soluble to dispersible. In certain cases, the solvent is selected such that it is capable of diffusing, dispersing, or leaching away from the composition in situ in an aqueous system and into fluids found at the administration site, thereby forming a solid implant. Preferably, the solvent has a Hildebrand solubility parameter of from 9 to 13 (cal/cm³)^(1/2). Preferably, the degree of polarity of the solvent is effective to provide at least 5% solubility in water.

Suitable organic solvents thus include, but are not limited to: substituted heterocyclic compounds such as N-methyl-2-pyrrolidone (NMP) and 2-pyrrolidone (2-pyrol); esters of carbonic acid and alkyl alcohols such as propylene carbonate, ethylene carbonate and dimethyl carbonate; fatty acids such as acetic acid, lactic acid and heptanoic acid; alkyl esters of mono-, di-, and tricarboxylic acids such as 2-ethyoxyethyl acetate, ethyl acetate, methyl acetate, ethyl lactate, ethyl butyrate, diethyl malonate, diethyl glutonate, tributyl citrate, diethyl succinate, tributyrin, isopropyl myristate, dimethyl adipate, dimethyl succinate, dimethyl oxalate, dimethyl citrate, triethyl citrate, acetyl tributyl citrate, glyceryl triacetate; alkyl ketones such as acetone and methyl ethyl ketone; ether alcohols such as 2-ethoxyethanol, ethylene glycol dimethyl ether, glycofurol and glycerol formal; alcohols such as ethanol and propanol; polyhydroxy alcohols such as propylene glycol, polyethylene glycol (PEG), glycerin (glycerol), 1,3-butyleneglycol, and isopropylidene glycol (2,2-dimethyl-1,3-dioxolone-4-methanol); Solketal; dialkylamides such as dimethylformamide, dimethylacetamide; dimethylsulfoxide (DMSO) and dimethylsulfone; tetrahydrofuran; lactones such as ε-caprolactone and butyrolactone; cyclic alkyl amides such as caprolactam; aromatic amides such as N,N-dimethyl-m-toluamide, and 1-dodecylazacycloheptan-2-one; and the like; and mixtures and combinations thereof. Preferred solvents include N-methyl-2-pyrrolidone, 2-pyrrolidone, dimethylsulfoxide, ethyl lactate, propylene carbonate, glycofurol, glycerol formal, and isopropylidene glycol.

In some cases, the organic solvent is present in an amount sufficient to dissolve the active pharmaceutical agent in the composition. For instance, the organic solvent may be present in the composition in an amount of at least 5 wt %, such as at least 10 wt %, at least 15 wt %, or at least 20 wt %, based on weight of the composition. The organic solvent may be present in the composition in an amount ranging from 5 wt % to 45 wt %, such as from 10 wt % to 35 wt %, from 15 wt % to 30 wt %, from 20 wt % to 25 wt %, or about 22 wt %, based on weight of the composition. The organic solvent may be provided in the composition in an amount of from 99.5 to 1 percent by weight relative to the total weight of the composition (wt %), in an amount of from 95 to 10 wt %, in an amount of from 75 to 25 wt %, or in an amount of from 60 to 40 wt %, depending upon the selected non-polymeric carrier, organic solvent, anesthetic agent, additive and/or excipient being used in the composition. In certain cases, the organic solvent diffuses or leaches away from the composition into an aqueous medium upon placement within a biological system, whereby the non-polymeric carrier material coagulates to form a solid matrix. In certain cases, the organic solvent diffuses or leaches away from the composition into an aqueous medium upon placement within a biological system, whereby the non-polymeric carrier material coagulates to form a semi-solid or gel. Preferably, the non-polymeric carrier solidifies in situ to form a solid matrix within 1 to 5 days after administration (implantation), preferably within 1 to 3 days, preferably within 2 hours.

In some cases, a triglyceride viscosity reducing agent is present in an amount ranging from 10 wt % to 50 wt %, 10 wt % to 35 wt %, 15 wt % to 30 wt %, or 20 wt % to 25 wt %, or about 15 wt %, 16 wt %, 17 wt %, 18 wt %, 19 wt %, 20 wt %, 21 wt %, 22 wt %, 23 wt %, 24 wt %, 25 wt %, 27 wt %, 28 wt %, 29 wt %, 30 wt %, 31 wt %, 32 wt %, 33 wt %, 34 wt %, or 35 wt % of the composition.

In some cases, an aprotic solvent is present in an amount ranging from 10 wt % to 35 wt %, 10 wt % to 30 wt %, 10 wt % to 20 wt %, 10 wt % to 15 wt %, or about 2 wt %, 3 wt %, 4 wt %, 5 wt %, 6 wt %, 7 wt %, 8 wt %, 9 wt %, 10 wt %, 11 wt %, 12 wt %, 13 wt %, 14 wt %, 15 wt %, 16 wt %, 17 wt %, 18 wt %, 19 wt %, or 20 wt % of the composition.

In some cases, compositions are provided wherein the non-polymeric carrier is a liquid. The liquid non-polymeric carrier is preferably a high viscosity liquid carrier material (“HVLCM”) to be non-water soluble, and has a viscosity of at least 5,000 cP, (and optionally at least 10,000, 15,000; 20,000; 25,000 or even 50,000 cP) at 37° C. that does not crystallize neat under ambient or physiological conditions. The term “non-water soluble” refers to a material that is soluble in water to a degree of less than one percent by weight under ambient conditions. The term “non-polymeric” refers to esters or mixed esters having essentially no repeating units in the acid moiety of the ester, as well as esters or mixed esters having acid moieties wherein functional units in the acid moiety are repeated a small number of times (i.e., oligomers). Generally, materials having more than five identical and adjacent repeating units or mers in the acid moiety of the ester are excluded by the term “nonpolymeric” as used herein, but materials containing dimers, trimers, tetramers, or pentamers are included within the scope of this term. When the ester is formed from hydroxy-containing carboxylic acid moieties that can further esterify, such as lactic acid or glycolic acid, the number of repeat units is calculated based upon the number of lactide or glycolide moieties, rather than upon the number of lactic acid or glycolic acid moieties, where a lactide repeat unit contains two lactic acid moieties esterified by their respective hydroxy and carboxy moieties, and where a glycolide repeat unit contains two glycolic acid moieties esterified by their respective hydroxy and carboxy moieties. Esters having 1 to 20 etherified polyols in the alcohol moiety thereof, or 1 to 10 glycerol moieties in the alcohol moiety thereof, are considered nonpolymeric as that term is used herein.

In a particular case, the HVLCM decreases in viscosity, in some cases significantly, when mixed with a solvent to form a low viscosity liquid carrier material (“LVLCM”) that can be administered using standard medical devices. The LVLCM composition is typically easier to place in the body than a HVLCM composition, because it flows more easily into and out of syringes or other implantation means. It also can easily be formulated as an emulsion. The LVLCM can have any desired viscosity, but its viscosity is generally lower than the corresponding HVLCM. As an example, viscosity ranges for the LVLCM of less than approximately 6,000 cP, less than approximately 4,000 cP, less than approximately 1,000 cP, or less than 200 cP, are typically useful for in vivo applications.

The particular HVLCM used in the compositions can be one or more of a variety of materials. Suitable materials include nonpolymeric esters or mixed esters of one or more carboxylic acids. In a particular case, the ester is formed from carboxylic acids that are esterified with a polyol having from 2 to 20 hydroxy moieties, and which may include 1 to 20 etherified polyols. Particularly suitable carboxylic acids for forming the acid moiety of the ester of the HVLCM include carboxylic acids having one or more hydroxy groups, e.g., those obtained by ring opening alcoholysis of lactones, or cyclic carbonates or by the alcoholysis of carboxylic acid anhydrides. Amino acids are also suitable for forming esters with the polyol. In a particular case, the ester or mixed ester contains an alcohol moiety having one or more terminal hydroxy moieties that have been esterified with one or more carboxylic acids obtained by alcoholysis of a carboxylic acid anhydride, such as a cyclic anhydride.

Non-limiting examples of suitable carboxylic acids that can be esterified to form the HVLCM include glycolic acid, lactic acid, ε-hydroxycaproic acid, serine, and any corresponding lactones or lactams, trimethylene carbonate, and dioxanone. The hydroxy-containing acids may themselves be further esterified through the reaction of their hydroxy moieties with additional carboxylic acid, which may be the same as or different from other carboxylic acid moieties in the material. Suitable lactones include, but are not limited to, glycolide, lactide, ε-caprolactone, butyrolactone, and valerolactone. Suitable carbonates include but are not limited to trimethylene carbonate and propylene carbonate.

The alcohol moiety of the ester or mixed ester may be derived from a polyhydroxy alcohol having from 2 to 20 hydroxy groups, and as indicated above, may be formed by etherifying 1 to 20 polyol molecules. Suitable alcohol moieties include those derived by removing one or more hydrogen atoms from: monofunctional C₁-C₂₀ alcohols, difunctional C₁-C₂₀ alcohols, trifunctional alcohols, hydroxy-containing carboxylic acids, hydroxy-containing amino acids, phosphate-containing alcohols, tetrafunctional alcohols, sugar alcohols, monosaccharides, and disaccharides, sugar acids, and polyether polyols. More specifically, the alcohol moieties may include one or more of: dodecanol, hexanediol, more particularly, 1,6-hexanediol, glycerol, glycolic acid, lactic acid, hydroxybutyric acid, hydroxyvaleric acid, hydroxycaproic acid, serine, ATP, pentaerythritol, mannitol, sorbitol, glucose, fructose, sucrose, glucuronic acid, polyglycerol ethers containing from 1 to 10 glycerol units, polyethylene glycols containing 1 to 20 ethylene glycol units.

In particular cases, at least one of the carboxylic acid moieties of the esters or mixed esters of the HVLCM comprise at least one oxy moiety In an even more particular case, each of the carboxylic acid moieties comprise at least one oxy moiety.

In another particular case, at least one of the carboxylic acid moieties of the esters or mixed esters contains 2 to 4 carbon atoms. In an even more particular case, each of the carboxylic acid moieties of the esters or mixed esters contains 2 to 4 carbon atoms.

In another more particular case, at least one of the carboxylic acid moieties of the ester or mixed ester has 2 to 4 carbon atoms and contains at least one oxy moiety. In another more particular case, each of the carboxylic acid moieties of the ester or mixed ester has 2 to 4 carbon atoms and contains at least one oxy moiety.

In a particular case, the HVLCM may be sucrose acetate isobutyrate (SAIB) or some other ester of a sugar alcohol moiety with one or more alkanoic acid moieties.

In a particular case, the HVLCM has a structure selected from the group consisting of:

wherein R¹, R², R³, R⁴, R⁵, R⁶, R⁷, and R⁸ are independently selected from the group consisting of hydrogen, alkanoyl, hydroxy-substituted alkanoyl, and acyloxy-substituted alkanoyl;

wherein at least three of R¹, R², R³, R⁴, R⁵, R⁶, R⁷, and R⁸ are other than hydrogen; and

wherein when R¹, R², R³, R⁴, R⁵, R⁶, R⁷, and R⁸ are selected from the group consisting of acetyl and isobutyryl, at least three of R¹, R², R³, R⁴, R⁵, R⁶, R⁷, and R⁸ are acetyl;

wherein R¹, R², and R³ are independently selected from the group consisting of hydrogen, alkanoyl, hydroxy-substituted alkanoyl, and acyloxy-substituted alkanoyl and wherein n is between 1 and 20;

wherein n is an integer between 4 and 8, and R¹ and R² are independently selected from the group consisting of hydrogen, alkanoyl, hydroxy-substituted alkanoyl, and acyloxy-substituted alkanoyl;

wherein in formulae IV and V, R¹, R², R³, R⁴, and R⁵ are independently selected from the group consisting of hydrogen, alkanoyl, hydroxy-substituted alkanoyl, and acyloxy-substituted alkanoyl;

wherein in formulae VI and VII, R¹, R², R³, R⁴, R⁵, and R⁶ are independently selected from the group consisting of hydrogen, alkanoyl, hydroxy-substituted alkanoyl, and acyloxy-substituted alkanoyl;

wherein R¹, R², R³, and R⁴ are independently selected from the group consisting of hydrogen, alkanoyl, hydroxy-substituted alkanoyl, and acyloxy-substituted alkanoyl.

In each of formulae I through VIII, one or more of the alkanoyl, hydroxy-substituted alkanoyl, and acyloxy-substituted alkanoyl groups may comprise alkanoyl moieties having 2 to 6 carbon atoms, including the carbonyl carbon. Moreover, in another more particular case, each of formulae I through VIII comprise at least one hydroxy-substituted or acyloxy-substituted alkanoyl moiety. In an even more particular case, at least one of these hydroxy-substituted or acyloxy-substituted alkanoyl moieties comprise alkanoyl moieties having 2 to 6 carbon atoms, including the carbonyl carbon.

The acyl groups forming the acyloxy substituents of the HVLCM may be any moiety derived from a carboxylic acid in accordance with the commonly accepted definition of the term “acyl.” More particularly, the acyl groups of the compositions may be of the form R⁹CO—, where R⁹ is optionally oxy-substituted alkyl of 2-6 carbon atoms. This oxy-substitution may take the form of hydroxy substitution, or substitution with additional acyl moieties. For example R⁹ may be an oligomer of oxy-substituted carboxylic acids, linked by ester bonding between the hydroxy of one acid and the carboxy of another acid. In a more particular example, R⁹ may comprise 1 to 5 lactide or glycolide units, where a lactide unit contains two lactic acid moieties esterified together and a glycolide unit contains two glycolic acid moieties esterified together. Alternatively, R⁹ may contain mixed lactide and glycolide units, or may contain mixed lactic acid and glycolic acid, without the presence of lactide or glycolide units.

Particular HVLCM materials include components according to formulae II or III, wherein R¹, R², and R³ are independently lactoyl, polylactoyl, ε-caproyl, hydroxyacetyl, or polyhydroxyacetyl, in particular, polylactoyl and ε-caproyl, or polylactoyl and polyhydroxyacetyl.

The use of relatively small chain (2 to 6 carbon atoms), oxy-substituted carboxylic acid moieties in the ester or mixed ester is advantageous. When these acid moieties are present in the form of oligomeric esters (i.e., a subsequent acid moiety joined to the previous acid moiety through esterification of the subsequent carboxy with the previous oxy), hydrolysis of the material is considerably easier than for oligomers made with more than 6 carbon atoms because the material is more hydrophilic. In general, for drug delivery it is desired that the HVLCM be water insoluble, but it may be somewhat hydrophilic. In general, HVLCMs synthesized with more hydrophilic units (as determined by a higher O:C ratio) will be expected to absorb water more rapidly and degrade more quickly. For example, a HVLCM made by covalently linking 4 moles of glycolide to one mole of glycerol will be expected to absorb water more rapidly and degrade more quickly than a HVLCM made by covalently linking 2 moles of glycolide and 2 moles of lactide to one mole of glycerol. Similar increases can be expected for more flexible molecules and for more branched, spherical molecules based on free volume arguments. Use of flexible and branched molecules may also have the benefit of lowering the viscosity of the LVLCM. Using carboxylic acids and/or polyols of different chain length and using carboxylic acids having oxy-substitution allows a precise control of the degree of hydrophilicity and of the solubility of the resulting ester. These materials are sufficiently resistant to dissolution in vivo that they are able to provide a sustained release of a carried anesthetic agent into the body accompanied or followed by oxy bonds hydrolyzing in vivo.

In an even more particular case, the HVLCM excludes the acetate and isobutyrate ester of sucrose having a ratio of acetate to isobutyrate acid moieties of 2:6. However, sucrose acetate isobutyrate ester having a ratio of acetate to isobutyrate moieties of 2:6 is included within the scope for use in aerosol formulations. This material can be made according to the procedures described in U.S. Pat. No. 2,931,802.

In general, suitable HVLCM esters can be made by reacting one or more alcohols, in particular one or more polyols, which will form the alcohol moiety of the resulting esters with one or more carboxylic acids, lactones, lactams, carbonates, or anhydrides of the carboxylic acids which will form the acid moieties of the resulting esters. The esterification reaction can be conducted simply by heating, although in some instances addition of a strong acid or strong base esterification catalyst may be used. Alternatively, an esterification catalyst such as stannous 2-ethylhexanoate can be used. The heated reaction mixture, with or without catalyst, is heated with stirring then dried, e.g., under vacuum, to remove any un-reacted starting materials and produce a liquid product. Sucrose acetate isobutyrates can be made by following the procedures described in U.S. Pat. No. 2,931,802.

In some cases, compositions of interest include sucrose acetate isobutyrate. In these cases, the sucrose acetate isobutyrate may be present in the composition in an amount based on weight of the bupivacaine composition from 10 wt % to 95 wt %, 10 wt % to 90 wt %, 15 wt % to 85 wt %, 20 wt % to 80 wt %, 25 wt % to 75 wt %, 30 wt % to 70 wt % or from 35 wt % to 65 wt %. For example, the sucrose acetate isobutyrate may be present in the composition in an amount based on weight of the bupivacaine composition of about 10 wt %, 11 wt %, 12 wt %, 13 wt %, 14 wt %, 15 wt %, 16 wt %, 17 wt %, 18 wt %, 19 wt %, 20 wt %, 21 wt %, 22 wt %, 23 wt %, 24 wt %, 25 wt %, 26 wt %, 27 wt %, 28 wt %, 29 wt %, 30 wt %, 31 wt %, 32 wt %, 33 wt %, 34 wt %, 35 wt %, 36 wt %, 37 wt %, 38 wt %, 39 wt %, 40 wt %, 41 wt %, 42 wt %, 43 wt %, 44 wt %, 45 wt %, 46 wt %, 47 wt %, 48 wt %, 49 wt %, 50 wt %, 51 wt %, 52 wt %, 53 wt %, 54 wt %, 55 wt %, 56 wt %, 57 wt %, 58 wt %, 59 wt %, 60 wt %, 61 wt %, 62 wt %, 63 wt %, 64 wt %, 65 wt %, 66 wt %, 67 wt %, 68 wt %, 69 wt %, 70 wt %, 71 wt %, 72 wt %, 73 wt %, 74 wt %, 75 wt %, 76 wt %, 77 wt %, 78 wt %, 79 wt %, 80 wt %, 81 wt %, 82 wt %, 83 wt %, 84 wt %, 85 wt %, 86 wt %, 87 wt %, 88 wt %, 89 wt %, 90 wt %. In certain cases, sucrose acetate isobutyrate is present in compositions at a level ranging from 60 wt % to 70 wt %, based on weight of the bupivacaine composition.

In some cases, peroxide is present in the sucrose acetate isobutyrate used to formulate the subject compositions. As noted above, the term “present” is used to specify that peroxide is present in the sucrose acetate isobutyrate in an amount greater than zero (e.g., at least a single molecule of peroxide is present in the sucrose acetate isobutyrate). In some cases, the peroxide is present in the sucrose acetate isobutyrate at a level less than 200 ppm, less than 195 ppm, less than 190 ppm, less than 185 ppm, less than 180 ppm, less than 175 ppm, less than 170 ppm, less than 165 ppm, less than 160 ppm, less than 155 ppm and including less than 150 ppm. For example, the subject compositions (e.g., bupivacaine composition containing bupivacaine, sucrose acetate isobutyrate and benzyl alcohol) is prepared using sucrose acetate isobutyrate having peroxide that is present at a level of 1 ppm, 2 ppm, 3 ppm, 4 ppm, 5 ppm, 6 ppm, 7 ppm, 8 ppm, 9 ppm, 10 ppm, 11 ppm, 12 ppm, 13 ppm, 14 ppm, 15 ppm, 16 ppm, 17 ppm, 18 ppm, 19 ppm, 20 ppm, 21 ppm, 22 ppm, 23 ppm, 24 ppm, 25 ppm, 26 ppm, 27 ppm, 28 ppm, 29 ppm, 30 ppm, 31 ppm, 32 ppm, 33 ppm, 34 ppm, 35 ppm, 36 ppm, 37 ppm, 38 ppm, 39 ppm, 40 ppm, 41 ppm, 42 ppm, 43 ppm, 44 ppm, 45 ppm, 46 ppm, 47 ppm, 48 ppm, 49 ppm, 50 ppm, 51 ppm, 52 ppm, 53 ppm, 54 ppm, 55 ppm, 56 ppm, 57 ppm, 58 ppm, 59 ppm, 60 ppm, 61 ppm, 62 ppm, 63 ppm, 64 ppm, 65 ppm, 66 ppm, 67 ppm, 68 ppm, 69 ppm, 70 ppm, 71 ppm, 72 ppm, 73 ppm, 74 ppm, 75 ppm, 76 ppm, 77 ppm, 78 ppm, 79 ppm, 80 ppm, 81 ppm, 82 ppm, 83 ppm, 84 ppm, 85 ppm, 86 ppm, 87 ppm, 88 ppm, 89 ppm, 90 ppm, 91 ppm, 92 ppm, 93 ppm, 94 ppm, 95 ppm, 96 ppm, 97 ppm, 98 ppm, 99 ppm, 100 ppm, 101 ppm, 102 ppm, 103 ppm, 104 ppm, 105 ppm, 106 ppm, 107 ppm, 108 ppm, 109 ppm, 110 ppm, 111 ppm, 112 ppm, 113 ppm, 114 ppm, 115 ppm, 116 ppm, 117 ppm, 118 ppm, 119 ppm, 120 ppm, 121 ppm, 122 ppm, 123 ppm, 124 ppm, 125 ppm, 126 ppm, 127 ppm, 128 ppm, 129 ppm, 130 ppm, 131 ppm, 132 ppm, 133 ppm, 134 ppm, 135 ppm, 136 ppm, 137 ppm, 138 ppm, 139 ppm, 140 ppm, 141 ppm, 142 ppm, 143 ppm, 144 ppm, 145 ppm, 146 ppm, 147 ppm, 148 ppm, 149 ppm, 150 ppm, 151 ppm, 152 ppm, 153 ppm, 154 ppm, 155 ppm, 156 ppm, 157 ppm, 158 ppm, 159 ppm, 160 ppm, 161 ppm, 162 ppm, 163 ppm, 164 ppm, 165 ppm, 166 ppm, 167 ppm, 168 ppm, 169 ppm, 170 ppm, 171 ppm, 172 ppm, 173 ppm, 174 ppm, 175 ppm, 176 ppm, 177 ppm, 178 ppm, 179 ppm, 180 ppm, 181 ppm, 182 ppm, 183 ppm, 184 ppm, 185 ppm, 186 ppm, 187 ppm, 188 ppm, 189 ppm, 190 ppm, 191 ppm, 192 ppm, 193 ppm, 194 ppm, 195 ppm, 196 ppm, 197 ppm, 198 ppm or 199 ppm.

In this regard, the polyol can be viewed as an oligomerization initiator, in the sense that it provides a substrate for esterification of carboxylic acids, in particular, of oligomers of lactide, glycolide, or other esterified hydroxy-substituted carboxylic acids.

In certain cases, the HVLCM can be mixed with a viscosity-lowering solvent to form a lower viscosity liquid carrier material (LVLCM), which can then be mixed with the one or more anesthetic agent to be delivered, prior to administration. These solvents can be water soluble, non-water soluble, or water miscible, and can include, acetone, benzyl alcohol, benzyl benzoate, N-(betahydroxyethyl) lactamidebutylene glycol, caprolactam, caprolactone, corn oil, decylmethylsulfoxide, dimethyl ether, dimethyl sulfoxide, 1-dodecylazacycloheptan-2-one, ethanol, ethyl acetate, ethyl lactate, ethyl oleate, glycerol, glycofurol (tetraglycol), isopropyl myristate, methyl acetate, methyl ethyl ketone, N-methyl-2-pyrrolidone, MIGLYOLs® (esters of caprylic and/or capric acids with glycerol or alkylene glycols, e.g., MIGLYOL® 810 or 812 (caprylic/capric triglycerides), MIGLYOL® 818 (caprylic/capric/linoleic triglyceride), MIGLYOL® 829 (caprylic/capric/succinic triglyceride), MIGLYOL® 840 (propylene glycol dicaprylate/caprate)), oleic acid, peanut oil, polyethylene glycol, propylene carbonate, 2-pyrrolidone, sesame oil, SOLKETAL ([±]-2,2-dimethyl-1,3-dioxolane-4-methanol), tetrahydrofuran, TRANSCUTOL® (diethylene glycol monoethyl ether, carbitol), triacetin, triethyl citrate, diphenyl phthalate, and combinations thereof. Additionally, if the composition is to be applied as an aerosol, e.g., for topical application, the solvent may be or may include one or more propellants, such as CFC propellants like trichlorofluoromethane and dichlorofluoromethane, non-CFC propellants like tetrafluoroethane (R-134a), 1,1,1,2,3,3,3-heptafluoropropane (R-227), dimethyl ether, propane, and butane.

Particularly suitable solvents and/or propellants include benzyl benzoate, benzyl alcohol, triacetin, triethyl citrate, dimethyl sulfoxide, ethanol, ethyl lactate, glycerol, glycofurol (tetraglycol), N-methyl-2-pyrrolidone, MIGLYOL® 810, polyethylene glycol, propylene carbonate, 2-pyrrolidone, and tetrafluoroethane.

Other possible solvents include perfluorodecalin, perfluorotributylamine, methoxyflurane, glycerolformal, tetrahydrofurfuryl alcohol, diglyme, and dimethyl isosorbide.

When the composition is used as a LVLCM to administer the anesthetic agent, it should contain a solvent that the HVLCM is soluble in. In certain instances, the anesthetic agent is also soluble in the solvent. In still further instances, the solvent is a second anesthetic agent in which the first anesthetic agent is soluble. The solvent is preferably non-toxic and otherwise biocompatible.

In certain cases, the solvent is at least water soluble, so that it will diffuse quickly into bodily fluids or other aqueous environment upon administration, causing the composition to coagulate and/or become more viscous. In some cases, the solvent is not completely miscible with water or bodily fluids so that diffusion of the solvent from the composition, and the corresponding increase in viscosity of the composition, are slowed. Suitable solvents that have this property, at least to some extent, include benzyl benzoate, MIGLYOL® 810, benzyl alcohol, and triethylcitrate. Benzyl alcohol can be particularly suitable, as it also an anesthetic agent.

When esters of 1,6-hexanediol or glycerol are used as the HVLCM, some possible solvents are ethanol, N-methylpyrrolidone, propylene carbonate, and PEG 400.

The solvent is typically added to the compositions in an amount in the range from 99.7 percent to 0.5 percent by weight relative to the total weight of the composition (wt %), from 95 percent to 1 wt %, from 75 to 10 wt %, or from 50 to 15 wt %. The solvent is typically present in the composition in an amount in the range from 55 percent to 10 wt %.

In still further cases, the composition includes a material that is not miscible with the HVLCM, such that when combined with the HVLCM singularly or in combination with a solvent for the HVLCM, the resulting composition forms an emulsion. Such emulsions may contain the HVLCM in the dispersed phase, such as in the case of SAIB/MIGLYOL® mixtures that are emulsified in water or glycerol, or they may contain the HVLCM as a component of the continuous phase, such as in the case of an aqueous solution that is emulsified in the HVLCM or a solution of the HVLCM in a water immiscible solvent.

In some cases, the delivery vehicle or system contains a polyorthoester polymer and a polar aprotic solvent. Also disclosed are low viscosity delivery systems for administration of active agents. In some cases, the low viscosity delivery systems comprise a polyorthoester polymer, a polar aprotic solvent and a solvent containing a triglyceride viscosity reducing agent.

Polyorthoesters useful for the compositions provided herein are generally composed of alternating residues resulting from reaction of a diketene acetal and a diol, where each adjacent pair of diketene acetal derived residues is separated by the residue of a reacted diol. The polyorthoester may comprise .alpha.-hydroxy acid-containing subunits, i.e., subunits derived from an .alpha.-hydroxy acid or a cyclic diester thereof, such as subunits comprising glycolide, lactide, or combinations thereof, i.e., poly(lactide-co-glycolide), including all ratios of lactide to glycolide, e.g., 75:25, 65:35, 50:50, etc. Such subunits are also referred to as latent acid subunits; these latent acid subunits also fall within the more general “diol” classification as used herein, due to their terminal hydroxyl groups. Polyorthoesters can be prepared as described, for example, in U.S. Pat. Nos. 4,549,010 and 5,968,543. Exemplary polyorthoesters suitable for use in the compositions provided herein are described in U.S. Pat. No. 8,252,304. The polyorthoester may be of the type and/or made as described in U.S. Pat. Nos. 8,252,305 and 10,213,510, which are herein incorporated by reference in their entireties.

The mole percentage of alpha-hydroxy acid containing subunits, R¹, generally ranges from 0 to 20 mol % of the total diol components (R¹ and R³ as provided below). In one or more cases, the mole percentage of alpha-hydroxy acid containing subunits in the polyorthoester formulation is at least 0.01 mole percent. Exemplary percentages of alpha-hydroxy acid containing subunits in the polymer are from 0 to 50 mole percent, or from 0 to 25 mole percent, or from 0.05 to 30 mole percent, or from 0.1 to 25 mole percent. For example, in one case, the percentage of alpha-hydroxy acid containing subunits in the polymer is from 0 to 50 mole percent. In another case, the percentage of alpha-hydroxy acid containing subunits in the polymer is from 0 to 25 mole percent. In yet another particular case, the percentage of alpha-hydroxy acid containing subunits in the polymer is from 0.05 to 30 mole percent. In yet another case, the percentage of alpha-hydroxy acid containing subunits in the polymer is from 0.1 to 25 mole percent. As an illustration, the percentage of alpha-hydroxy acid containing subunits may be 0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 24, 26, 27, 28, 29 or 30 mole percent, including any and all ranges lying therein, formed by combination of any one lower mole percentage number with any higher mole percentage number.

Exemplary polyorthoesters possess a weight average molecular weight of 1000 Da to 200,000 Da, for example from 2,500 Da to 100,000 Da or from 3,500 Da to 20,000 Da or from 4,000 Da to 10,000 Da or from 5,000 Da to 8,000 Da. Illustrative molecular weights, in Da, are 2500, 5000, 5500, 6000, 6500, 7000, 7500, 8000, 8500, 9000, 9500, 10,000, 20,000, 30,000, 40,000, 50,000, 60,000, 70,000, 80,000, 90,000, 100,000, 120,000, 150,000, 175,000 and 200,000, and ranges therein, wherein exemplary ranges include those formed by combining any one lower molecular weight as described above with any one higher molecular weight as provided above, relative to the selected lower molecular weight.

In one particular case related to the polyorthoester in the delivery system, the polyorthoester has a molecular weight ranging from 2,500 daltons to 10,000 daltons.

In some cases, the composition comprises 40% to 75%, 40% to 60%, 45% to 55%, 65 to 75%, or about 40%, 45%, 50%, 55%, 60%, 65%, 70%, or 75% by weight of the composition.

A number of suitable additives may be included with the composition in order to impart selected characteristics upon the composition. For example, they may include a minor amount of a biodegradable thermoplastic polymer such as a polylactide, polycaprolactone, polyglycolide, or copolymer thereof, in order to provide a more coherent solid implant or a composition with greater viscosity so as to hold it in place while it solidifies. Such thermoplastic polymers are disclosed in U.S. Pat. No. 4,938,763 to Dunn et al.

Optionally, a pore-forming agent can be included in the composition. The pore-forming agent can be any organic or inorganic, pharmaceutically-acceptable substance that is substantially soluble in water or body fluid, and will dissipate from the non-polymeric carrier material and/or the solid matrix of an implant into surrounding body fluid at the implant site. The pore-forming agent may preferably be insoluble in the organic solvent to form a uniform mixture with the non-polymeric carrier material. The pore-forming agent may also be a water-immiscible substance that rapidly degrades to a water-soluble substance. In certain compositions, the pore-forming agent is combined with the non-polymeric carrier and organic solvent in admixture. Suitable pore-forming agents that can be used in the composition include, for example, sugars such as sucrose and dextrose, salts such as sodium chloride and sodium carbonate, polymers such as hydroxylpropylcellulose, carboxymethylcellulose, polyethylene glycol and polyvinylpyrrolidone, and the like. Solid crystals that will provide a defined pore size, such as salt or sugar, are preferred.

As discussed above, a variety of additives can optionally be added to the compositions to modify the properties thereof, and in particular to modify the release properties of the composition with respect to the anesthetic agents contained therein. The additives can be present in any amount sufficient to impart the desired properties to the composition. The amount of additive used will in general be a function of the nature of the additive and the effect to be achieved, and can be easily determined by one of ordinary skill in the art. Suitable additives are described in U.S. Pat. No. 5,747,058, the entire contents of which are hereby incorporated by reference. More particularly, suitable additives include water, biodegradable polymers, non-biodegradable polymers, natural oils, synthetic oils, carbohydrates or carbohydrate derivatives, inorganic salts, BSA (bovine serum albumin), surfactants, organic compounds, such as sugars, and organic salts, such as sodium citrate. In general, the less water soluble, i.e., the more lipophilic, the additive, the more it will decrease the rate of release of the anesthetic agent, compared to the same composition without the additive. In addition, it may be desirable to include additives that increase properties such as the strength or the porosity of the composition.

The addition of additives can also be used to lengthen the delivery time for the anesthetic agent, making the composition suitable for medical applications requiring or responsive to longer-term administration. Suitable additives in this regard include those disclosed in U.S. Pat. Nos. 5,747,058 and 5,736,152. In particular, suitable additives for this purpose include polymeric additives, such as cellulosic polymers and biodegradable polymers. Suitable cellulosic polymers include cellulose acetates, cellulose ethers, and cellulose acetate butyrates. Suitable biodegradable polymers include polylactones, polyanhydrides, and polyorthoesters, in particular, polylactic acid, polyglycolic acid, polycaprolactone, and copolymers thereof.

When present, the additive is typically present in the compositions in an amount in the range from 0.01 percent to 20 percent by weight, more particularly from 0.1 percent to 20 percent by weight, relative to the total weight of the composition, and more typically, is present in the composition in an amount in the range from 1, 2, or 5 percent to 10 percent by weight. Certain additives, such as buffers, are only present in small amounts in the composition.

The following categories are nonlimiting examples of classes of additives that can be employed in the compositions.

Additives include biodegradable polymers and oligomers. The polymers can be used to alter the release profile of the anesthetic agent to be delivered, to add integrity to the composition, or to otherwise modify the properties of the composition. Non-limiting examples of suitable biodegradable polymers and oligomers include: poly(lactide), poly(lactide-co-glycolide), poly(glycolide), poly(caprolactone), polyamides, polyanhydrides, polyamino acids, polyorthoesters, polycyanoacrylates, poly(phosphazines), poly(phosphoesters), polyesteramides, polydioxanones, polyacetals, polyketals, polycarbonates, polyorthocarbonates, degradable polyurethanes, polyhydroxybutyrates, polyhydroxyvalerates, polyalkylene oxalates, polyalkylene succinates, poly(malic acid), chitin, chitosan, and copolymers, terpolymers, oxidized cellulose, or combinations or mixtures of the above materials.

Examples of poly(α-hydroxy acid)s include poly(glycolic acid), poly(DL-lactic acid) and poly(L-lactic acid), and their copolymers. Examples of polylactones include poly(ε-caprolactone), poly(δ-valerolactone) and poly(γ-butyrolactone).

While not wishing to be bound by any theory, it is believed that when the composition contains a biodegradeable polymer, a portion of the polymer may precipitate or coagulate at the surface of the composition as any included solvent diffuses away from the material after administration to the subject. The polymer may thus be added as a release modifying agent to affect the release of the anesthetic agent or agents, or may be added as part of a composition containing pre-formed microspheres, implants, or ground polymer particles. The precipitation or coagulation of the polymer forms a skin at least partially surrounding the liquid core of such composition. This skin is porous, and allows the solvent to continue to diffuse through it into surrounding tissue. The rate of solvent release and the extent of formation of the skin, as well as its porosity, can be controlled by the amount and type of solvent and polymer used in the composition.

Other additives for use with the present compositions are non-biodegradable polymers. Non-limiting examples of nonerodible polymers which can be used as additives include: polyacrylates, ethylene-vinyl acetate polymers, cellulose and cellulose derivatives, acyl substituted cellulose acetates and derivatives thereof, non-erodible polyurethanes, polystyrenes, polyvinyl chloride, polyvinyl fluoride, polyvinyl (imidazole), chlorosulphonated polyolefins, polyethylene oxide, and polyethylene.

Preferred non-biodegradable polymers include polyvinyl pyrrolidone, ethylene vinylacetate, polyethylene glycol, cellulose acetate butyrate (“CAB”) and cellulose acetate propionate (“CAP”).

A further class of additives which can be used in the present compositions are natural and synthetic oils and fats. Oils derived from animals or from plant seeds of nuts typically include glycerides of the fatty acids, chiefly oleic, palmitic, stearic, and linoleic. As a rule the more hydrogen the molecule contains the thicker the oil becomes.

Non-limiting examples of suitable natural and synthetic oils include vegetable oil, peanut oil, medium chain triglycerides, soybean oil, almond oil, olive oil, sesame oil, fennel oil, camellia oil, corn oil, castor oil, cotton seed oil, and soybean oil, either crude or refined, and medium chain fatty acid triglycerides.

Fats are typically glyceryl esters of higher fatty acids such as stearic and palmitic. Such esters and their mixtures are solids at room temperatures and exhibit crystalline structure. Lard and tallow are examples. In general oils and fats increase the hydrophobicity of a non-polymeric carrier system, slowing degradation and water uptake.

Any of the above-described sustained delivery systems can be formulated as liquid, spray, cream, lotion, ointment, gel, slurry, oil, emulsion, microemulsion, solid, plaster, film, particle, microparticle, powder or other suitable form pharmaceutical compositions, suitable for use in the methods. In such compositions, the anesthetic agent (e.g., the first anesthetic agent) is included in an amount sufficient to deliver to the subject to be treated an effective amount to achieve a desired effect. The amount of anesthetic agent incorporated into the composition depends upon the final desired release duration and profile, and the concentration of anesthetic required for the intended effect.

Both soluble and insoluble anesthetic agents can be distributed using the non-polymeric carrier materials for sustained release delivery. Moreover, the compositions may be further formulated with polymeric excipients to provide a delivery matrix with modified properties, for example a faster or slower degradation rate. The resulting composition may be formed into microspheres, or into a macroscopic implant, or other geometries and sizes according to techniques known in the art. Alternatively, a pre-formed microsphere, implant, or polymer particle with the anesthetic agent or agents incorporated therein can be combined with the non-polymeric carrier.

Microspheres may be prepared by a number of methods known in the art, as well as methods described in U.S. Pat. Nos. 6,291,013 and 6,440,493. The polymer particle may be formed using melt extrusion, granulation, solvent mixing, absorption, or like techniques, or the anesthetic agent may be adsorbed onto a polymer matrix, such as an ion exchange resin. The resulting material, when combined suitable non-polymeric carrier material may be administered parenterally. In other cases, the anesthetic agent may be combined with a non-polymeric material, such as calcium phosphate or sucrose, to provide layering/barrier properties that lengthen degradation. The non-polymeric carrier will then form a secondary barrier to provide enhanced delivery characteristics. The non-polymeric carrier phase may or may not contain other biologically active substances, according to the specific requirement of the selected application. These other biologically active agents may be any suitable therapeutic and/or prophylactic pharmaceutical, provided that the added substance is suitable for incorporation into microspheres or implants according to techniques known in the art.

In some cases, the compositions include an amide- or anilide-type local anesthetic of the “caine” classification, and a non-steroidal anti-inflammatory drug (NSAID), along with related methods, e.g., for treatment of post-operative pain. In some cases, a sustained-release delivery vehicle is a polymeric formulation in the form of a semi-solid polymer formulation comprising a polyorthoester, the amide-type local anesthetic and a non-steroidal anti-inflammatory drug (NSAID). In some cases, the non-steroidal anti-inflammatory drug (NSAID) is an enolic-acid NSAID. Exemplary enolic-acid NSAID include meloxicam, piroxicam, tenoxicam, droxicam, lornoxicam, and isoxicam. In a specific case, the enolic-acid NSAID is meloxicam. In certain cases, a composition comprises: 1-5 wt % bupivacaine; 0.005-0.125 wt % meloxicam; optionally, maleic acid; 5-12 wt % dimethylsulfoxide or N-methylpyrrolidone; 10-40 wt % triacetin; and 55-67 wt % polyorthoester (e.g., having a Mw 2.5-10 kDa).

All of the above-described compositions may be used in the methods of the present disclosure in order to provide sustained local anesthesia at a target site. In particular, the compositions may be formulated as liquid, spray, cream, lotion, ointment, gel, slurry, oil, emulsion, microemulsion, solid, plaster, film, particle, microparticle, powder or any other suitable pharmaceutical composition form and then administered to a subject via topical, ophthalmic, transdermal, parenteral (e.g, injection, implant, etc.) or like delivery techniques. The compositions, containing an anesthetic and a pharmaceutically acceptable non-polymeric carrier, are used to provide an anesthetic effect characterized by sustained local anesthesia after administration to the subject without an initial burst and a duration of at least 24 hours after administration, preferably 36 to 48 hours after administration, and more preferably 48 to 72 hours after administration. In certain cases, the onset of the local anesthesia occurs within 2 hours of administration to the subject, preferably within 1 hour of administration, and in some cases within 30 minutes of administration to the subject.

In some cases, the compositions of the present disclosure are suited for use in the treatment of wounds. The non-polymeric carrier systems allow the anesthetic agent or agents to be easily applied to the wound, either directly within the wound and/or adjacent to the wound, using very simple application techniques such dropping on, spraying, painting, spreading, molding or otherwise manually manipulating a liquid, spray, cream, lotion, ointment, gel, slurry, oil, emulsion, microemulsion, pliable solid or plaster, film, particle, microparticle, or powder composition into the wound. The compositions can thus be used with any sized or shaped wound, and will provide an even distribution of the anesthetic agent or agents over the entire area of the wound for better retention and efficacy. Wounds that can be treated using such methods my range for the most superficial to deep, from surface to incisional and from surgical (or otherwise deliberate) to accidental. If the composition is to be injected, it may be applied to the subcutaneous space using a trailing injection alongside the wound on all sides or outside boundaries. Combination approaches may also be employed, such as where the composition is both laid directly into the wound, e.g., prior to surgical closure of the sound, and additionally along the wound. In a particularly preferred case, the methods of the present disclosure involve the use of the instant compositions as a local anesthetic for treatment of post-operative incisional pain. Use of the present compositions in this manner may obviate or at least mitigate the necessity to provide adjunct therapies, such as the administration of systemic narcotic analgesics in order to treat such post-operative pain. Accordingly, the compositions may be used to treat post-operative pain that accompanies all types of medical procedures, such as major surgeries (e.g., thoracotomy, aortic repair, bowel resection), intermediate surgeries (e.g., caesarean section, hysterectomy and appendectomy), and minor surgeries (laparoscopy, arthroscopy, and biopsy procedures), that can otherwise be debilitating and may require pain treatment for 3 to 5 days after surgery.

The compositions described herein can thus be administered in the practice of the instant methods using a wide variety of methods. For example, the compositions may be administered topically, ophthalmically, systematically (for example, mucosally (orally, rectally, vaginally, or nasally), parenterally (intravenously, subcutaneously, intramuscularly, or intraperitoneally), or the like. The compositions may be applied via injection, pouring, spray dip, aerosol, or coating applicator. Aerosols or mists of the composition can be administered using an aerosol propellant, e.g., for topical administration, or using a suitable nebulizer, e.g., for nasal, or oral mucosal administration.

Preferably, the compositions are administered as liquids via injection, or in an aerosol, paste or emulsion. When used in an aerosol, any solvent present in the aerosol solution will typically evaporate upon application, allowing the composition to set-up as a film. Alternatively, the aerosol or emulsion may be prepared without a solvent. In this situation, the aerosol propellant can also function as a solvent. Formation of aerosols and emulsions can be accomplished using techniques known to those skilled in the art. See, for example, Ansel, H. C. et al., Pharmaceutical Dosage Forms and Drug Delivery Systems, Sixth Edition (1995).

In addition to the uses described above, the present compositions can be administered through osmotic pumps. In one case, a device is designed to be implanted in the tissue of the subject, and designed to effect sustained release over time.

It is also possible to administer the compositions using a porous or nonporous tube, desirably made of extruded biodegradeable polymer. The tube may be prepared with varying degrees of porosity depending on the characteristics of the composition and the release characteristics desired. The composition is inserted into the tube, and the ends of the tube may be left open, allowing biologically active compound to diffuse out of the ends of the tube, or may be closed off with additional porous or nonporous polymer. Porous endcaps and porous tubes allow active compound to diffuse through the pores over time. Nonporous endcaps, as well as nonporous tubes, allow anesthetic agents that are soluble in the polymer to diffuse through it and into surrounding tissues. Nonporous materials that are not solvents for the anesthetic, but that are biodegradable, will release the anesthetic when they degrade sufficiently. The compositions may be prepared and stored as multi-component systems until ready for administration. The number of different components will depend, in part, on the characteristics of the composition. Prior to administration, the components are combined and mixed, e.g., to achieve a homogeneous composition, which can then be administered to the subject. Solvents or additives may be added to one or all of the components, or may form a separate component, which is also mixed with the others prior to administration. Separation of the composition into a multicomponent mixture allows the storage conditions for each component to be optimized, and minimizes any detrimental interactions between components over time. The result is increased storage stability.

In some cases, compositions of the present disclosure do not require dilution. The term “dilution” is used herein in its conventional sense to refer to the addition of a component (e.g., fluidic component such as a solvent) to reduce the concentration of the one or more components of the compositions, such as reducing the concentration of the active agent component in the composition. In some instances, the subject compositions are not diluted with water or other solvent.

In some cases, compositions of the present disclosure do not require further mixing. The phrase “further mixing” is used herein in its conventional sense to refer to additional steps of processing the composition to generate a uniform, homogeneous or usable mixture of the components. In certain instances, the compositions do not require any agitation prior to use. In other instances, the compositions do not require any shaking or repeated inversion of the sample container prior to use.

The present disclosure also relates to a plurality of strategies to improve stability and safety of sustained release drug delivery formulations. The strategies include improved sterilization, prevention of light induced degradation, and inert container closures, and low metal content.

In some aspects, the present disclosure relates to sustained release drug delivery formulations having low amounts of 2,6-dimethylaniline (Formula I):

In some cases, the 2,6-dimethylaniline is present in the drug delivery formulation at a level less than 500 ppm, such as less than 300 ppm, less than 200 ppm, less than 100 ppm, less than 15 ppm, less than 12 ppm, less than 10 ppm, or less than 5 ppm. In some cases, the 2,6-dimethylaniline is present in the drug delivery formulation at a level ranging from 0.2 ppm to 500 ppm, such as from 0.3 ppm to 200 ppm, from 0.4 ppm to 100 ppm, from 0.5 ppm to 10 ppm, or 2 ppm to 8 ppm. For example, 2,6-dimethylaniline in the composition (e.g., bupivacaine composition containing bupivacaine, sucrose acetate isobutyrate and benzyl alcohol) may be present at a level of from 1 ppm to 10 ppm, from 10 ppm to 20 ppm, from 20 ppm to 30 ppm, from 30 ppm to 40 ppm, from 40 ppm to 50 ppm, from 50 ppm to 60 ppm, from 60 ppm to 70 ppm, from 70 ppm to 80 ppm, from 80 ppm to 90 ppm, from 90 ppm to 100 ppm, from 100 ppm to 110 ppm, from 110 ppm to 120 ppm, from 120 ppm to 130 ppm, from 130 ppm to 140 ppm, from 140 ppm to 150 ppm, from 150 ppm to 160 ppm, from 160 ppm to 170 ppm, from 170 ppm to 180 ppm, from 180 ppm to 190 ppm, from 190 ppm to 200 ppm, from 200 ppm to 210 ppm, from 210 ppm to 220 ppm, from 220 ppm to 230 ppm, from 230 ppm to 240 ppm, from 240 ppm to 250 ppm, from 250 ppm to 260 ppm, from 260 ppm to 270 ppm, from 270 ppm to 280 ppm, from 280 ppm to 290 ppm, from 290 ppm to 300 ppm, from 300 ppm to 310 ppm, from 310 ppm to 320 ppm, from 320 ppm to 330 ppm, from 330 ppm to 340 ppm, from 340 ppm to 350 ppm, from 350 ppm to 360 ppm, from 360 ppm to 370 ppm, from 370 ppm to 380 ppm, from 380 ppm to 390 ppm, from 390 ppm to 400 ppm, from 400 ppm to 410 ppm, from 410 ppm to 420 ppm, from 420 ppm to 430 ppm, from 430 ppm to 440 ppm, from 440 ppm to 450 ppm, from 450 ppm to 460 ppm, from 460 ppm to 470 ppm, from 470 ppm to 480 ppm, from 480 ppm to 490 ppm, from 490 ppm to 500 ppm.

In some cases, the present disclosure relates to compositions having low amounts of N-oxide of the active pharmaceutical agent. For instance, the N-oxide of the active pharmaceutical agent may be present in the composition at a level less than 1 wt %, such as less than 0.7 wt %, less than 0.5 wt %, or less than 0.4 wt %, based on weight of the composition. In some cases, the N-oxide of the active pharmaceutical agent is present in the composition at a level ranging from 0.01 wt % to 1 wt %, such as from 0.05 wt % to 0.4 wt %, 0.1 wt % to 0.4 wt %, or from 0.1 wt % to 0.2 wt %, based on weight of the composition. If the level of the N-oxide of the active pharmaceutical agent is too high, the composition may have reduced efficacy, which may be problematic. In some aspects, the present disclosure relates to sustained release drug delivery formulations having low amounts of bupivacaine N-oxide (Formula II):

In some cases, the bupivacaine N-oxide is present in the composition at a level less than 1 wt %, such as less than 0.7 wt %, or less than 0.4 wt %, based on weight of the composition. In some cases, the bupivacaine N-oxide is present in the composition at a level ranging from 0.01 wt % to 1 wt %, such as from 0.05 wt % to 0.4 wt %, or from 0.1 wt % to 0.2 wt %, based on weight of the composition.

In some cases, compositions are made from ingredients having low levels of peroxide. For instance, the compositions may be made by combining: an active pharmaceutical agent; a high viscosity liquid carrier material (HVLCM) comprising sucrose acetate isobutyrate having peroxide that is present at a level less than 200 ppm; and an organic solvent. In some cases, the sucrose acetate isobutyrate has peroxide that is present at a level less than 100 ppm, such as less than 80 ppm or less than 60 ppm. In some cases, the sucrose acetate isobutyrate has peroxide that is present at a level ranging from 1 ppm to 100 ppm, such as from 2 ppm to 80 ppm or from 3 ppm to 60 ppm.

In some cases, the compositions may be made by combining: an active pharmaceutical agent; a high viscosity liquid carrier material (HVLCM) comprising sucrose acetate isobutyrate; and an organic solvent, such as benzyl alcohol, having peroxide that is present at a level less than 100 ppm. In some cases, the organic solvent has peroxide that is present at a level less than 85 ppm, such as less than 10 ppm. In some cases, the organic solvent has peroxide that is present at a level ranging from 1 ppm to 90 ppm, such as from 2 ppm to 85 ppm or from 3 ppm to 10 ppm.

In some cases, the amount of degradation products (e.g., 2,6-dimethylaniline, bupivacaine N-oxide) in the subject compositions may be measured by HPLC with UV detection. In other cases, the amount of 2,6-dimethylaniline is determined by nuclear magnetic resonance (NMR) spectroscopy. In other cases, the amount of 2,6-dimethylaniline is determined by gas chromatography (e.g., gas chromatography-mass spectrometry, GCMS). In some cases, the amount of 2,6-dimethylaniline is determined by liquid chromatography (e.g., liquid chromatography-mass spectrometry, LCMS). Unless specified otherwise, the amount of 2,6-dimethylaniline recited in the claims is determined by LCMS. In some cases, the amount of 2,6-dimethylaniline may be measured by electrochemical detection as described in FIJALEK et al., Journal of Pharmaceutical and Biomedical Analysis, 37:913-918 (2005), which is incorporated herein by reference in its entirety.

In some cases, the amount of peroxide is measured by potentiometric titration, e.g., iodometric titration. Other techniques for measuring the amount of peroxide include voltamperometric method, spectrophotometry (e.g., using cobalt bicarbonate with light absorbance measured at 400 nm, titanium oxalate with light absorbance measured at 260 nm, or peroxidase enzyme with light absorbance measured at 596 nm), fluorometry, fluorescence correlation spectroscopy (FCS), chemiluminescence, electrochemistry, ion chromatography (IC), and resonance light scattering (RLS). Unless specified otherwise, the amount of peroxide recited in the claims is determined by spectrophotometry using cobalt bicarbonate with light absorbance measured at 400 nm.

In one aspect, the present disclosure relates to sterilization of sustained release drug delivery formulations without the formation of unacceptable levels of degradation products including genotoxic impurities.

It was discovered that, in some cases, gamma irradiation is not an acceptable sterilization method because gamma irradiation significantly increased levels of degradation products, including a known genotoxic degradant, 2,6-dimethylaniline. The formation of of 2,6-dimethylaniline as a result of gamma irradiation was surprising because gamma irradiation is associated with oxidation reactions, whereas formation of 2,6-dimethylaniline involves a hydrolysis reaction.

An evaluation of alternate sterilization techniques was conducted using an exemplary formulation consisting of 12 wt % bupivacaine, 66 wt % sucrose acetate isobutyrate (SAIB), and 22 wt % benzyl alcohol (“Formulation A”). The sterilization techniques included: dry heat sterilization, steam sterilization, and filtration sterilization followed by aseptic processing. The evaluation concluded that:

-   -   In some cases, the use of dry heat to sterilize was not         acceptable because dry heat sterilization temperatures were         above the flash point of the product and required that the         product be exposed to elevated temperatures for extended periods         of time. The flash point of Formulation A is 116° C. (closed         cup); a typical sterilization cycle is 170° C. for not less than         2 hours. Although precautions may be taken to heat product to         this temperature, the safety of the personnel and plant did not         justify the risk. In addition, in some cases,         fluorocarbon-coated stoppers cannot withstand typical dry heat         sterilization (e.g., 250° C. for ≥30 minutes).     -   The use of steam to sterilize Formulation A was not acceptable         because the formulation is non-aqueous. Steam sterilization uses         saturated steam at high pressure to denature cells. Aqueous         products in vials use the water in the formulation to create         this steam and pressure within the headspace of the container,         sterilizing the contents. Additionally, steam sterilization         temperatures are above the flash point of the product, creating         the same safety issue as described for dry heat sterilization.     -   The use of filtration sterilization followed by aseptic         processing for Formulation A is acceptable because it provides         the product with a sterility assurance level of greater than         10⁻³ without compromising the product. In addition, the inherent         anti-microbial activity of the Formulation A ensures that         pre-filtration bioburden will be consistently low, thereby,         ensuring a safe filter sterilization outcome.

Therefore, the optimal sterilization method for manufacturing the exemplary formulation is filtration sterilization followed by aseptic processing. As used herein, “aseptic processing” means processing under sterile conditions. Aseptic processing eliminates the risk of product degradation and toxicity that would arise if the product was subjected to ionizing radiation at doses sufficient to comply with current ISO requirements (e.g., 20 kGy to 25 kGy of gamma irradiation). In some cases, the subject compositions are sterile. The term “sterile” as used herein means having a low bioburden, effectively being germ-free, e.g., being free from microorganisms, e.g., bacteria and viruses, e.g., meeting the USP/EP test for sterility current as of the filing date of the present document. Sterilization is the process of reducing the bioburden to an effectively germ-free level.

In some cases, the subject compositions are nonpyrogenic.

In addition to finalizing aseptic processing as the choice of sterilization techniques, a processing study was conducted that identified the optimal compounding and filling temperatures to minimize the formation of 2,6-dimethylaniline during manufacture.

In some cases, methods of the present disclosure include processing the subject compositions. Methods of processing the subject compositions according to certain cases, include filtering a composition having one or more active agents (e.g., anesthetic, NSAID, etc. as described below) and aseptically processing the composition. In cases, the composition (as described in greater detail below) may be filtered using a filter having pore sizes which vary, ranging from 0.1 nm to 1000 nm, such as from 0.5 nm to 950 nm, such as from 1 nm to 900 nm, such as from 10 nm to 800 nm, such as from 25 nm to 750 nm, such as from 50 nm to 500 nm and including filtering with a filter having pore sizes of from 100 nm to 400 nm. The composition may be filtered under positive, negative or atmospheric pressure. The composition may be filtered while heating the composition. In some instances, the composition is heated by 1° C. or more during filtration, such as by 2° C. or more, such as 3° C. or more, such as by 4° C. or more, such as by 5° C. or more, such as by 10° C. or more, such as by 15° C. or more, such as by 20° C. or more and including by 25° C. or more. In some cases, the composition is heated to a temperature of from 10° C. to 75° C. during filtration, such as from 15° C. to 70° C., such as from 20° C. to 65° C., such as from 25° C. to 60° C., such as from 30° C. to 55° C. and including from 40° C. to 50° C.

In some case, aseptic processing of the composition includes filling the composition into a container under a gaseous atmosphere. In some instances, the gaseous atmosphere includes an inert gas. Inert gases of interest may include, but are not limited to, nitrogen, helium, neon, argon, krypton, xenon, and carbon dioxide or a combination thereof. In some cases, the amount of gas is sufficient to fill the headspace of the container. The term “headspace” is used herein in its conventional sense to refer to the volume in the container between the interface of the composition and the opening of the container or at the interface of the closure (e.g., when the container is sealed with a stopper). The gas pressure of the inert gas atmosphere in the headspace of the container may be 0.001 torr or more, such as 0.005 torr or more, such as 0.01 torr or more, such as 0.05 torr or more, such as 0.1 torr or more, such as 0.5 torr or more, such as 1 torr or more, such as 5 torr or more, such as 10 torr or more, such as 25 torr or more, such as 50 torr or more, such as 100 torr or more, such as 250 torr or more, such as 500 torr or more, such as 760 torr or more and including 1000 torr or more.

In some instances, aseptic processing of the composition includes closing the container with a closure. In some cases, the closure is formed from (or coated with) a compound that is inert to the components of the subject compositions (as described in greater detail below). In some cases, the closure forms a fluidic seal with the container. In other cases, the closure forms a fluidic and gaseous seal with the container.

It was discovered that, in some cases, exposure to light (e.g., simulated sunlight, sunlight, UV light, and visible light) can result in formation of degradation products in sustained release drug delivery formulations.

It was also discovered that, in some cases, storage of sustained release drug delivery formulations in amber colored glassware causes the levels of 2,6-dimethylaniline to be high. The formation of of 2,6-dimethylaniline as a result of amber glassware was surprising because iron oxide in the amber glassware is associated with oxidation reactions, whereas formation of 2,6-dimethylaniline involves a hydrolysis reaction.

In some cases, the light induced degradation is prevented by storing the product in appropriate light resistant cartons.

In some cases, the drug delivery formulation is stored in a light resistant container. In some cases, the light resistant container comprises a protective light resistant coating, e.g., RAY-SORB® coating. In some cases, the subject light resistant containers are configured to reduce or eliminate light-induced degradation by preventing exposure of the subject compositions to light having a wavelength that ranges from 200 nm to 800 nm, such as from 225 nm to 775 nm, such as from 250 nm to 750 nm, such as from 275 nm to 725 nm, such as from 300 nm to 700 nm, such as from 325 nm to 675 nm, such as from 350 nm to 650 nm, such as from 375 nm to 625 nm and including from 400 nm to 600 nm. In certain cases, the light resistant containers have an optical density at the wavelength where a reduction in light exposure is desired of 0.5 or more, such as 1 or more, such as 1.5 or more, such as 2.0 or more, such as 2.5 or more, such as 3.0 or more, such as 3.5 or more, such as 4.0 or more, such as 4.5 or more, such as 5.0 or more, such as 5.5 or more, such as 6.0 or more, such as 6.5 or more and including an optical density of 7.0 or more. In certain instances, the light resistant container is completely opaque to the wavelength of light where reduction of light exposure is desired (i.e., no light passes through the walls of the container).

It was discovered that, in some cases, siliconized stoppers leach silicone oil into sustained release drug delivery formulations. In some cases, dose units of the subject compositions are stored (e.g., loaded, dispensed from) in a container having a closure (e.g., a stopper, lid or cap) that is substantially inert to components of the composition, such as to the organic solvent present in the composition (e.g., benzyl alcohol). As used herein, “substantially inert” means that the subject composition does not leach from or react with the closure (i.e., contact between the composition and the closure does not result in the formation or presence of degradation or undesired byproducts in the composition). In some cases, the closure exhibits no reactivity with the composition even when in contact for 1 hour or longer, such as for 2 hours or longer, such as for 6 hours or longer, such as for 12 hours or longer, such as for 24 hours or longer, such as for 1 week or longer, such as for 1 month or longer, such as for 6 months or longer, such as for 1 year or longer and including for 10 years or longer. In some instances, closures of interest include fluorinated polymer. In some cases, the closure is formed from the fluorinated polymer. In other cases, the closure is coated with the fluorinated polymer. Fluorinated polymers of interest may include but are not limited to fluoropolymers formed from one or more monomers selected from the group ethylene-tetrafluoroethylene, perfluorocycloalkene (PFCA), vinyl fluoride (fluoroethylene, VF1), vinylidene fluoride (1,1-difluoroethylene, VDF, VF2), tetrafluoroethylene (TFE), chlorotrifluoroethylene (CTFE), hexafluoropropylene (HFP), perfluoropropylvinylether (PPVE), perfluoromethylvinylether (PMVE). For instance, the closure may be formed from polyvinylfluoride (PVF), polyvinylidene fluoride (PVDF), polytetrafluoroethylene (PTFE), polychlorotrifluoroethylene (PCTFE), perfluoroalkoxypolymer (PFA), fluorinated ethylene-propylene (FEP), polyethylenetetrafluoroethylene (ETFE), polyethylenechlorotrifluoroethylene (ECTFE), perfluorinated elastomer (FFPM/FFKM), fluorocarbon chlorotrifluoroethylenevinylidene fluoride (FPM), fluoroelastomer tetrafluoroethylene-propylene (FEPM), perfluoropolyether (PFPE) or perfluorosulfonic acid (PFSA). In certain cases, the closure does not include silicon.

In some cases, the stopper is paired with a glass container (e.g., glass vial), e.g., a 10 mL USP Type I Glass Vial. In some cases, the glass vial is pyrex glass, a boron silica glass or other type of glass. In certain instances, the glass vial is formed from a glass material which does not contain iron.

In some cases, the presence of organic solvent, e.g., 22 wt % benzyl alcohol, necessitated the selection of a stopper that was chemically resistant to organic solvents.

In some cases, the present disclosure provides dosage systems that are free of silicone oil.

In some cases, the present disclosure provides a fluorocarbon-coated stopper that can release fluoride ions when exposed to gamma irradiation. As a result, in some cases, the dosage system is not exposed to gamma irradiation.

In some cases, the present disclosure involves control of metal content in sustained release drug delivery formulations.

The manufacturing of sustained release drug delivery formulations, from the source of raw materials to the compounding, filling, and storage in containers (e.g., glass vials with stoppers), may be conducted in a way to minimize metals in the final product. In some cases, the metal content is minimized by using steel compounding tanks. In some cases, the metal content is minimized by using silicone tubing. In some cases, the metal content is minimized by using fluorocarbon-coated stoppers.

In some cases, a composition comprises metal present at a level less than 5 ppm, such as less than 4 ppm, or less than 3 ppm. In some cases, the composition comprises metal present at a level ranging from 0.1 ppm to 4 ppm, such as from 0.05 ppm to 3 ppm or from 0.1 ppm to 2 ppm. A skilled artisan would understand that the metal content includes metal in any form, including metal in elemental or ionized form.

In some cases, the present disclosure relates to a composition having low water content. For instance, the water may be present at a level less than 0.5 wt %, such as less than 0.4 wt %, based on weight of the composition, or less than 0.3 wt %, based on weight of the composition. The water may be present in the composition at a level ranging from 0.03 wt % to 0.4 wt %, such as from 0.05 wt % to 0.35 wt %, from 0.08 wt % to 0.3 wt %, based on weight of the composition.

While not wishing to be bound by theory, in some cases, the water content is believed to affect the amount of hydrolysis that occurs in the compositions. In some cases, sucrose acetate isobutyrate and benzyl alcohol undergo a hydrolysis reaction to form benzyl acetate and/or benzyl isobutyrate. The formation of benzyl acetate and/or benzyl isobutyrate is surprising to the extent that significant formation of benzyl acetate and/or benzyl isobutyrate does not occur in vehicle compositions comprising benzyl alcohol and sucrose acetate isobutyrate. It appears that bupivacaine catalyzes transesterification to form the benzyl acetate and/or benzyl isobutyrate. The formation of benzyl acetate and/or benzyl isobutyrate is potentially problematic as it may lead to precipitation. It is believed that keeping the water content low reduces the amount of benzyl acetate and benzyl isobutyrate formation. The water content may be kept low by several techniques, such as using ingredients with low water content, storing ingredients in closed containers, drying sterilizing filters prior to use, using an inert gas (e.g., nitrogen) to force the composition through the sterilizing filters, and using an inert gas (e.g., nitrogen) head space while compounding and storing in containers.

In view of the above, in some cases, the present disclosure involves compositions having low benzyl acetate content. For instance, the benzyl acetate may be present at a level less than 100 mg/mL, such as less than 90 mg/mL, less than 80 mg/mL, less than 70 mg/mL, less than 60 mg/mL, less than 50 mg/mL, less than 40 mg/mL, less than 30 mg/mL, less than 20 mg/mL, less than 15 mg/mL, or less than 10 mg/mL. The benzyl acetate may be present in the composition at a level ranging from 0.1 mg/mL to 80 mg/mL, such as from 0.5 mg/mL to 40 mg/mL, from 1 mg/mL to 20 mg/mL, or 1 mg/mL to 15 mg/mL. In some cases, the benzyl acetate is present in the composition in an amount of 1 mg/mL, 2 mg/mL, 3 mg/mL, 4 mg/mL, 5 mg/mL, 6 mg/mL, 7 mg/mL, 8 mg/mL, 9 mg/mL, 10 mg/mL, 11 mg/mL, 12 mg/mL, 13 mg/mL, 14 mg/mL, 15 mg/mL, 16 mg/mL, 17 mg/mL, 18 mg/mL, 19 mg/mL, 20 mg/mL, 21 mg/mL, 22 mg/mL, 23 mg/mL, 24 mg/mL, 25 mg/mL, 26 mg/mL, 27 mg/mL, 28 mg/mL, 29 mg/mL, 30 mg/mL, 31 mg/mL, 32 mg/mL, 33 mg/mL, 34 mg/mL, 35 mg/mL, 36 mg/mL, 37 mg/mL, 38 mg/mL, 39 mg/mL, 40 mg/mL, 41 mg/mL, 42 mg/mL, 43 mg/mL, 44 mg/mL, 45 mg/mL, 46 mg/mL, 47 mg/mL, 48 mg/mL, 49 mg/mL, 50 mg/mL, 51 mg/mL, 52 mg/mL, 53 mg/mL, 54 mg/mL, 55 mg/mL, 56 mg/mL, 57 mg/mL, 58 mg/mL, 59 mg/mL, 60 mg/mL, 61 mg/mL, 62 mg/mL, 63 mg/mL, 64 mg/mL, 65 mg/mL, 66 mg/mL, 67 mg/mL, 68 mg/mL, 69 mg/mL, 70 mg/mL, 71 mg/mL, 72 mg/mL, 73 mg/mL, 74 mg/mL, 75 mg/mL, 76 mg/mL, 77 mg/mL, 78 mg/mL, 79 mg/mL, 80 mg/mL, 81 mg/mL, 82 mg/mL, 83 mg/mL, 84 mg/mL, 85 mg/mL, 86 mg/mL, 87 mg/mL, 88 mg/mL, 89 mg/mL, 90 mg/mL, 91 mg/mL, 92 mg/mL, 93 mg/mL, 94 mg/mL, 95 mg/mL, 96 mg/mL, 97 mg/mL, 98 mg/mL, 99 mg/mL or 100 mg/mL.

In some cases, the present disclosure involves compositions having low benzyl isobutyrate content. For instance, the benzyl isobutyrate may be present at a level less than 50 mg/mL, such as less 40 mg/mL, less than 30 mg/mL, less than 20 mg/mL, less than 10 mg/mL, or less than 8 mg/mL. The benzyl isobutyrate may be present in the composition at a level ranging from 0.1 mg/mL to 40 mg/mL, such as from 0.5 mg/mL to 30 mg/mL, from 1 mg/mL to 10 mg/mL, or 1 mg/mL to 8 mg/mL. In some cases, the benzyl isobutyrate is present in the composition in an amount of 1 mg/mL, 2 mg/mL, 3 mg/mL, 4 mg/mL, 5 mg/mL, 6 mg/mL, 7 mg/mL, 8 mg/mL, 9 mg/mL, 10 mg/mL, 11 mg/mL, 12 mg/mL, 13 mg/mL, 14 mg/mL, 15 mg/mL, 16 mg/mL, 17 mg/mL, 18 mg/mL, 19 mg/mL, 20 mg/mL, 21 mg/mL, 22 mg/mL, 23 mg/mL, 24 mg/mL, 25 mg/mL, 26 mg/mL, 27 mg/mL, 28 mg/mL, 29 mg/mL, 30 mg/mL, 31 mg/mL, 32 mg/mL, 33 mg/mL, 34 mg/mL, 35 mg/mL, 36 mg/mL, 37 mg/mL, 38 mg/mL, 39 mg/mL, 40 mg/mL, 41 mg/mL, 42 mg/mL, 43 mg/mL, 44 mg/mL, 45 mg/mL, 46 mg/mL, 47 mg/mL, 48 mg/mL, 49 mg/mL or 50 mg/mL.

While not wishing to be bound by theory, in some cases, it is believed that the amount of peroxide in the composition may affect the amount of N-oxide formation. Reducing the amount of peroxide is believed to reduce the amount of N-oxide formation. The amount of peroxide in the composition may be kept low by several techniques, such as using ingredients that have low peroxide content, protecting the composition from light, minimizing the headspace in the container containing the composition, and storing the composition at low temperature, such as from 15° C. to 30° C., such as room temperature.

In some cases, the present the composition is made with HVLCM (e.g., sucrose acetate isobutyrate) having low peroxide content. For instance, the HVLCM may have peroxide present at a level less than 200 ppm, such less than 100 ppm, less than 80 ppm, or less than 60 ppm. In some cases, the HVLCM has peroxide that is present at a level ranging from 1 ppm to 100 ppm, such as from 2 ppm to 80 ppm or from 3 ppm to 60 ppm.

In some cases, the present the composition is made with organic solvent (e.g., benzyl alcohol) having low peroxide content. For instance, the organic solvent may have peroxide that is present at a level less than 100 ppm, such as less than 85 ppm or less than 10 ppm. In some cases, the organic solvent has peroxide that is present at a level ranging from 1 ppm to 90 ppm, such as from 2 ppm to 85 ppm or from 3 ppm to 10 ppm.

In other aspects, the present disclosure relates to active agent compositions (e.g., bupivacaine compositions) having little to no particulate matter. In some cases, particulate matter is present in the compositions at a level less than 100 ppm, less than 95 ppm, less than 90 ppm, less than 85 ppm, less than 80 ppm, less than 75 ppm, less than 70 ppm, less than 65 ppm, less than 60 ppm, less than 55 ppm and including less than 50 ppm. For example, particulate matter may be present in the compositions at a level of 1 ppm, 2 ppm, 3 ppm, 4 ppm, 5 ppm, 6 ppm, 7 ppm, 8 ppm, 9 ppm, 10 ppm, 11 ppm, 12 ppm, 13 ppm, 14 ppm, 15 ppm, 16 ppm, 17 ppm, 18 ppm, 19 ppm, 20 ppm, 21 ppm, 22 ppm, 23 ppm, 24 ppm, 25 ppm, 26 ppm, 27 ppm, 28 ppm, 29 ppm, 30 ppm, 31 ppm, 32 ppm, 33 ppm, 34 ppm, 35 ppm, 36 ppm, 37 ppm, 38 ppm, 39 ppm, 40 ppm, 41 ppm, 42 ppm, 43 ppm, 44 ppm, 45 ppm, 46 ppm, 47 ppm, 48 ppm, 49 ppm, 50 ppm, 51 ppm, 52 ppm, 53 ppm, 54 ppm, 55 ppm, 56 ppm, 57 ppm, 58 ppm, 59 ppm, 60 ppm, 61 ppm, 62 ppm, 63 ppm, 64 ppm, 65 ppm, 66 ppm, 67 ppm, 68 ppm, 69 ppm, 70 ppm, 71 ppm, 72 ppm, 73 ppm, 74 ppm, 75 ppm, 76 ppm, 77 ppm, 78 ppm, 79 ppm, 80 ppm, 81 ppm, 82 ppm, 83 ppm, 84 ppm, 85 ppm, 86 ppm, 87 ppm, 88 ppm, 89 ppm, 90 ppm, 91 ppm, 92 ppm, 93 ppm, 94 ppm, 95 ppm, 96 ppm, 97 ppm, 98 ppm, 99 ppm, 100 ppm. In certain cases, the composition has no particulate matter, i.e., 0 ppm particulate matter.

The stability of the formulations also depends on storage conditions. High temperature storage typically increases degradation. In some cases, low temperature storage can cause precipitation. Thus, the compositions of the present disclosure are typically stored at at a temperature ranging from 15° C. to 30° C., such as from 20° C. to 25° C.

In some cases, when a composition is stored in a sealed, upright, clear glass vial at 25° C./60% RH for 20 months or 36 months, the 2,6-dimethylaniline is present at levels disclosed herein, e.g., when the composition is stored in a sealed, upright, clear glass vial at 25° C./60% RH for 20 months or 36 months, the 2,6-dimethylaniline may be present at a level less than 500 ppm. In some cases, when a composition is stored in a sealed, upright, clear glass vial at 25° C./60% RH for 20 months or 36 months, the 2,6-dimethylaniline is present at a level less than 10 times, such as less than 8 times, less than 6 times, less than 4 times, or less than 2 times, relative to an initial level before storage, such as ranging from 1 time to 10 times, such as 2 times to 6 times, or 2 times to 4 times, relative to an initial level before storage.

In some cases, when a composition is stored in a sealed, upright, clear glass vial at 40° C./75% RH for 20 months or 36 months, the 2,6-dimethylaniline is present at levels disclosed herein. In some cases, when a composition is stored in a sealed, upright, clear glass vial at 40° C./75% RH for 20 months or 36 months, the 2,6-dimethylaniline is present at a level less than 10 times, such as less than 8 times, less than 6 times, less than 4 times, or less than 2 times, relative to an initial level before storage such as ranging from 1 time to 10 times, such as 2 times to 6 times, or 2 times to 4 times, relative to an initial level before storage.

In some cases, when a composition is stored in a sealed, upright, clear glass vial at 25° C./60% RH for 20 months or 36 months, the N-oxide of the active pharmaceutical agent is present at levels disclosed herein, e.g., at a level less than 1 wt %, based on weight of the composition. In some cases, when a composition is stored in a sealed, upright, clear glass vial at 25° C./60% RH for 20 months or 36 months, the N-oxide of the active pharmaceutical agent is present at a level less than 2 times or less than 1.5 times relative to an initial level before storage, such as ranging from 1 time to 2 times or 1 time to 1.5 times, relative to an initial level before storage.

In some cases, when a composition is stored in a sealed, upright, clear glass vial at 40° C./75% RH for 20 months or 36 months, the N-oxide of the active pharmaceutical agent is present at levels disclosed herein, e.g., at a level less than 1 wt %, based on weight of the composition. In some cases, when a composition is stored in a sealed, upright, clear glass vial at 40° C./75% RH for 20 months or 36 months, the N-oxide of the active pharmaceutical agent is present at a level less than 2 times or less than 1.5 times, relative to an initial level before storage, such as ranging from 1 time to 2 times or 1 time to 1.5 times, relative to an initial level before storage.

In some cases, when a composition is stored in a sealed, upright, clear glass vial at 25° C./60% RH for 20 months or 36 months, the metal is present at levels disclosed herein, e.g., at a level less than 5 ppm. In some cases, when a composition is stored in a sealed, upright, clear glass vial at 40° C./75% RH for 20 months or 36 months, the metal is present at levels disclosed herein.

In some cases, when a composition is stored in a sealed, upright, clear glass vial at 25° C./60% RH for 20 months or 36 months, the water is present at levels disclosed herein, e.g., at a level less than 0.5 wt %, based on weight of the composition. In some cases, when a composition is stored in a sealed, upright, clear glass vial at 40° C./75% RH for 20 months or 36 months, the water is present at levels disclosed herein.

In some cases, when a composition is stored in a sealed, upright, clear glass vial at 25° C./60% RH for 20 months or 36 months, the benzyl acetate is present at levels disclosed herein, e.g., at a level less than 100 mg/mL. In some cases, when a composition is stored in a sealed, upright, clear glass vial at 25° C./60% RH for 20 months or 36 months, the benzyl acetate is present at a level less than 20 times or less than 15 times, relative to an initial level before storage, such as ranging from 1 time to 20 times or 2 times to 15 times, relative to an initial level before storage.

In some cases, when a composition is stored in a sealed, upright, clear glass vial at 40° C./75% RH for 20 months or 36 months, the benzyl acetate is present at levels disclosed herein, e.g., at a level less than 100 mg/mL. In some cases, when a composition is stored in a sealed, upright, clear glass vial at 40° C./75% RH for 20 months or 36 months, the benzyl acetate is present at a level less than 20 times or less than 15 times, relative to an initial level before storage, such as ranging from 1 time to 20 times or 2 times to 15 times, relative to an initial level before storage.

In some cases, when a composition is stored in a sealed, upright, clear glass vial at 25° C./60% RH for 20 months or 36 months, the benzyl isobutyrate is present at levels disclosed herein, e.g., at a level less than 50 mg/mL. In some cases, when a composition is stored in a sealed, upright, clear glass vial at 25° C./60% RH for 20 months or 36 months, the benzyl isobutyrate is present at a level less than 10 times or less than 8 times, relative to an initial level before storage, such as ranging from 1 time to 10 times or 2 times to 8 times, relative to an initial level before storage.

In some cases, when a composition is stored in a sealed, upright, clear glass vial at 40° C./75% RH for 20 months, the benzyl isobutyrate is present at levels disclosed herein, e.g., at a level less than 50 mg/mL. In some cases, when a composition is stored in a sealed, upright, clear glass vial at 40° C./75% RH for 20 months, the benzyl isobutyrate is present at a level less than 10 times or less than 8 times, relative to an initial level before storage, such as ranging from 1 time to 10 times or 2 times to 8 times, relative to an initial level before storage.

In some cases, when a composition is stored in a sealed, upright, clear glass vial at 25° C./60% RH for 20 months or 36 months, the sucrose acetate isobutyrate is present at levels disclosed herein, e.g., at a level ranging from 30 wt % to 80 wt %, based on weight of the composition. In some cases, when a composition is stored in a sealed, upright, clear glass vial at 40° C./75% RH for 20 months, the sucrose acetate isobutyrate is present at levels disclosed herein, e.g., at a level ranging from 30 wt % to 80 wt %, based on weight of the composition.

In some cases, degradation of the active pharmaceutical agent may result in formation of 2,6-dimethylaniline. For instance, the active pharmaceutical agent may be at least one member selected from bupivacaine, lidocaine, ropivicaine, etidocaine, mepivacaine, pyrrocaine, or salts thereof.

In some cases, the active pharmaceutical agent is present in the composition in an amount ranging from 1 wt % to 25 wt %, such as from 5 wt % to 20 wt %, from 10 wt % to 15 wt %, or about 12 wt %, based on weight of the composition.

EXPERIMENTAL SECTION

The below examples are offered for illustrative purposes only, and are not intended to limit the scope of the present invention in any way.

Example 1

A randomized, double-blinded, active- and placebo-controlled study was conducted to evaluate the efficacy and safety of Formulation A for post-operative pain control in patients following arthroscopic shoulder surgery.

Objectives

The objective was to identify the optimal dose of Formulation A for post-operative pain control administered into the subacromial space in patients undergoing elective arthroscopic shoulder surgery on the basis of efficacy, pharmacokinetics (PK), and safety evaluations.

Methods

The study was a parallel group, randomized, double-blinded, active- and placebo-controlled, dose response trial of Formulation A with post-operative assessments of pain intensity (PI), PK, safety, and health economics in patients undergoing elective arthroscopic shoulder surgery, comprising up to a 14-day screening period, a 7-day post-surgical period, an EOT visit at Day 14, and a follow-up visit after six months.

Composition: Formulation A Active ingredient: Bupivacaine base Inactive ingredients: Sucrose acetate isobutyrate, benzyl alcohol Administration: Varied, based on surgical procedure, interstitial (FDA Code 088) either by tissue infiltration, injection or needle-free deposition for general surgical applications. Strength: 132 mg/mL, 660 mg bupivacaine

Composition Placebo Active ingredient: Not applicable Inactive ingredients: Sucrose acetate isobytyrate, benzyl alcohol Administration: Varied, based on surgical procedure, interstitial (FDA Code 088) either by tissue infiltration, injection or needle-free deposition for general surgical applications.

Composition: Active Control Active ingredient: Bupivacaine HCl Inactive ingredients: Sterile isotonic solution containing sodium chloride Administration: Varied, based on surgical procedure, interstitial (FDA Code 088) either by tissue infiltration, injection or needle-free deposition for general surgical applications. Strength: 20 mL of 2.5 mg/mL, 50 mg

Patients were screened 1 to 14 days before surgery at which time informed consent was obtained. Surgery was performed and the trial drug administered on Day 0. The trial was planned to be divided into two sequential cohorts, each with three treatment groups (a, b and c). After screening, the first patients were randomized 2:1:1 to the treatment groups in cohort 1: 1a) 5 mL Formulation A (660 mg bupivacaine) subacromial administration; 1b) 5 mL placebo subacromial administration; and 1c) 20 mL standard bupivacaine hydrochloride (HCl) 0.25% w/v (50 mg bupivacaine) administered subacromially. After finalization of cohort 1, data was analyzed and, based on the efficacy, safety and PK results presented in this clinical trial report (CTR), a decision was made regarding whether the second cohort (cohort 2) would be initiated, and whether new patients would be recruited and treated at the higher dosage of Formulation A: 2a) 7.5 mL Formulation A (990 mg bupivacaine) administered subacromially; 2b) 7.5 mL placebo administered subacromially; and 2c) 20 mL standard bupivacaine HCl (50 mg bupivacaine) administered subacromially. The Data Review Committee recommended that an increase in dose to 7.5 mL of Formulation A was not expected to provide a clinically significant improvement in efficacy. Therefore, the trial did not include the 7.5 mL Cohort 2.

All patients received paracetamol (4 grams/day; 2 grams/day for body weight <66 kg for the first 72 hours) as background treatment. In case sufficient pain relief was not obtained, patients were allowed rescue medication in the form of morphine administered intravenously or orally, which consisted of oral morphine 10 mg at 1-hour intervals or, if unable to tolerate orally intake, intravenous (IV) morphine 2 g at 5-minute intervals. After 72 hours, subjects were allowed paracetamol and oral morphine on an as-needed basis. Patients recorded pain intensity as well as rescue medication in an electronic diary (eDiary).

Diagnosis and Main Criteria for Inclusion/Exclusion:

Subjects with subacromial impingement syndrome and an intact rotator cuff established by magnetic resonance imaging (MRI) and who were suitable for general anesthesia were eligible for inclusion. Patients with other shoulder pathology or who had serious medical conditions or who were unable to tolerate the study drug were excluded.

Formulation A, Dose and Mode of Administration:

9.0 mL Formulation A (132 mg bupivacaine/mL) per vial. Following surgery, 5 mL Formulation A (660 mg bupivacaine) (cohort 1) was administered into the subacromial space through one of the arthroscopic portals or by injection through intact skin under direct arthroscopic vision to confirm placement of the needle tip within the suvacromial space. Formulation A was administered once only following completion of surgery.

Reference Composition, Dose and Mode of Administration:

This trial was placebo-controlled and had an active comparator arm. Placebo (5 mL) was administered using the same method as for Formulation A. The active comparator was standard bupivacaine HCl (20 mL of 2.5 mg/mL) was administered subacromially as a single dose.

Criteria for Evaluation Efficacy

Primary: The study had two primary endpoints. The primary efficacy endpoints were: PI on movement area under the curve AUC over the time period 1 to 72 hours post-surgery measured by an 11-point Numerical Rating Scale (NRS); and total use of opioid rescue analgesia 0 to 72 hours after surgery. For the primary endpoints to be met, non-inferiority of PI on movement compared to placebo as well as superiority in total use of opioid analgesia needed to be shown. PI “on movement” reported on the NRS scale was summarized by treatment group and time, using descriptive statistics for continuous variables.

Secondary: Time to first opioid rescue medication usage; Opioid-Related Symptom Distress Scale (OR-SDS) score Days 0 to 7 post-surgery; PI at rest AUC over the period 1 to 72 hours post-surgery; patient's pain treatment satisfaction score on Day 4 post-surgery; proportion of patients who were dischargeable (according to the Post-Anaesthetic Discharge Scoring System [PADS]) on Days 1, 2, 3, 4 and 7 post-surgery; and proportion of patients who had returned to work by Day 14 post-surgery. Time to first opioid rescue medication usage was defined as the duration between time of trial drug administration and the time of first opioid use

Pharmacokinetics

Total and free bupivacaine plasma concentrations were measured for the Formulation A and standard bupivacaine HCl groups for evaluation of bupivacaine PK, including maximum concentrations of bupivacaine. Additionally, alpha 1 acid glycoprotein (AAG) plasma concentrations were measured in these two groups for correlation with free bupivacaine concentrations.

Pharmacokinetic/pharmacodynamic (PK/PD) relationships were to be assessed as part of central nervous system (CNS) toxicity monitoring and cardiac monitoring. For patients not selected for PK-profiling, if a cardiac or CNS event occurred that met the criteria for a serious adverse event (SAE) or a severe non-SAE, a blood sample for PK analysis was to be taken as close to the event as possible.

Safety

The incidence of adverse events (AEs); the incidence of bupivacaine-related CNS side effects; clinical laboratory tests; vital signs; 12-lead ECGs; and physical examinations.

Other Assessments

Evaluation by the investigator of wound healing and tissue conditions at the surgical wound on Days 7 and 14, and at the 6-month follow-up visit. An MRI of the shoulder as well as a functionality assessment of the shoulder using the Constant-Murley score were to be performed at the 6-month follow-up visit.

Results

Primary Efficacy Endpoints

The mean PI on movement AUC over the time period 1 to 72 hours post-surgery (ITT population) is summarized in Table 1.1. The Formulation A group was shown to be statistically superior over placebo for the time period 1 to 72 hours post-surgery (p-value: 0.012). The PI on movement over time for the ITT population is shown in FIG. 1.

TABLE 1.1 Pain intensity on movement, mean AUC (LOCF) (ITT population) Treatment Variable n Mean SD 95% CI p-value Formulation AUC (1-24 53 5.16 2.04 A 5 mL AUC (24-48 51 5.38 2.23 AUC (48-72 53 4.87 2.33 AUC (1-48 53 5.31 1.94 AUC (1-72 53 5.16 1.94 Placebo AUC (1-24 24 7.31 1.89 5 mL AUC (24-48 24 6.62 1.93 AUC (48-72 25 5.57 2.06 AUC (1-48 25 6.88 1.82 AUC (1-72 25 6.43 1.77 Standard AUC (1-24 29 5.82 2.30 Bupivacaine AUC (24-48 29 5.31 2.70 HCl AUC (48-72 29 4.38 2.48 AUC (1-48 29 5.56 2.43 AUC (1-72 29 5.16 2.38 Difference: AUC (1-24 106 −2.14 0.52 Formulation AUC (24-48 104 −1.22 0.58 A 5 mL AUC (48-72 107 −0.68 0.56 minus AUC (1-48 107 −1.56 0.50 [−2.56; −0.56] 0.002 Placebo 5 mL AUC (1-72 107 −1.27 0.50 [−2.25; −0.28] 0.012 Difference: AUC (1-24 106 −0.66 0.49 Formulation AUC (24-48 104 0.03 0.54 A 5 mL AUC (48-72 107 0.48 0.54 minus AUC (1-48 107 −0.27 0.48 [−1.22; 0.69]  Standard AUC (1-72 107 −0.02 0.47 [−0.96; 0.92]  Bupivacaine HCl n = number of patients with available data; SD = standard deviation; CI = confidence interval; AUC = area under the curve; LOCF = last observation carried forward; ITT = intention to treat. LS Mean difference and standard error is presented for treatment differences. P-value from ANOVA with treatment group and trial site in the model.

Significantly less opioid rescue medication was taken by subjects treated with Formulation A than placebo (Table 1.2). The median cumulative IV morphine-equivalent dose of opioids from 0 to 72 hours after treatment was 4.0 mg for the Formulation A group and 12.0 mg for the placebo group (p=0.0130). The median cumulative dose was 8.0 mg for the bupivacaine HCl group. Postoperative opioid rescue medication use was analyzed nonparametrically because it did not meet prespecified normality assumptions. The percentage of subjects that remained opioid free during the 72 hours after surgery was also significantly greater in the Formulation A group than the placebo group: 39.6% v. 16.0% (P=0.027). The percentage abstaining from opioids in the bupivacaine HCl group was 27.6%.

TABLE 1.2 Total IV morphine equivalent dose of opioid rescue medication taken from 0-72 hours after surgery, ITT population Bupivacaine Placebo Formulation A HCl (N = 25) (N = 53) (N = 29) Min, max, mg 0, 92 0, 176 0, 66 Median, mg 12.0 4.0 8.0 Median difference −8.0 vs placebo, mg ^([1]) 95% CI −12.0, 0.0 P-value ^([2]) 0.0100 Median difference 0.0 vs bupivacaine HCl, mg ^([1]) 95% CI −4.6, 0.0 P-value ^([2]) — CI, confidence interval; ITT, intent-to-treat; IV, intravenous ^([1]) Hodges-Lehmann estimates for median difference ^([2]) Wilcoxon rank-sum test

Secondary Efficacy Variables

Treatment with Formulation A significantly prolonged the time to first postsurgical use of opioid rescue medication compared with placebo (Table 1.3). The median time to first use was 12.4 hours for the Formulation A group and 1.2 hours for the placebo group (p=0.0137). The median time to first use was 1.4 hours for the bupivacaine HCl group.

TABLE 1.3 Time to first use of opioid rescue medication, ITT population Bupivacaine Placebo Formulation A HCl (N = 25) (N = 53) (N = 29) Min, Max 0.0, 14.2 0.0, 36.6 0.0, 10.9 Median (95% CI), hours ^([1]) 1.2 (0.7, 1.5) 12.4 (1.2, —) 1.4 (1.0, 4.1) P-value for 0.0137 median difference vs placebo ^([2]) P-value for — median difference vs bupivacaine HCl ^([2]) CI, confidence interval; ITT, intention-to-treat; min, minimum; max, maximum Note: Subjects who did not use opioid rescue medication on-study were censored at their last study visit. ^([1]) Median time from study treatment to administration of an opioid medication reported as a concomitant medication, based on Kaplan-Meier survival estimates. ^([2]) Log-rank test.

Comparison of the OR-SDS scores on Day 0 to 7 did not reveal any statistically significant differences between treatment groups (Formulation A versus placebo and Formulation A versus standard bupivacaine HCl).

Overall, 81 patients (75.7% of patients in the ITT population) experienced at least one opioid-related side effect in the period Day 0 to 3, the frequency and number of patients experiencing all opioid-related side effects was similar across all treatment groups. Drowsiness, fatigue and dizziness were the most frequent opioid-related symptoms recorded for the total (ITT) population in the period Day 0 to 3.

Table 1.4 summarizes PI at rest normalized AUC 1-72 hours post surgery for the ITT population. As with PI on movement, Formulation A significantly reduced PI over 72 hours compared to Placebo. The difference between Formulation A and Bupivacaine HCl was not significant.

TABLE 1.4 Pain intensity at rest normalized AUC 1-72 hours, ITT population Bupivacaine Placebo Formulation A HCl (N = 25) (N = 53) (N = 29) Mean (SD) ^([1]) 3.43 (2.05) 2.50 (1.34) 2.33 (1.76) LS mean difference (SE) −0.91 (0.39) vs placebo ^([1]) 95% CI −1.68, −0.14 P-value ^([2]) 0.021 LS mean difference (SE) 0.12 (0.37) vs bupivacaine HCl ^([1]) 95% CI −0.62, 0.85 P-value ^([2]) — AUC, area under the curve; CI, confidence interval; SD, standard deviation; SE, standard error of the mean ^([1]) ANOVA model with treatment group and country as factors; missing pain scores imputed by last observation carried forward for subjects discontinuing before 72 hours, first observation carried backward for missing initial pain scores, and linear interpolation for missing pain scores between two non-missing scores. ^([2]) t-test in an ANOVA model.

On Day 4, the majority of patients were either satisfied (59.8% of patients) or very satisfied (27.1% of patients) with the pain treatment they had received for their surgery. Only one patient was very dissatisfied with her pain treatment (in the Formulation A group) and four patients were dissatisfied (three in the Formulation A group and one in the standard bupivacaine HCl group).

There were no statistically significant differences in the patients' pain satisfaction score (on Day 4 after surgery had been performed) between the treatment groups; Formulation A against placebo (p-value: 0.995) and Formulation A against standard bupivacaine HCl (p-value 0.699).

There were no statistically significant differences between the treatment groups in the patients' home-readiness on either day. The odds ratio for the pair-wise comparisons of Formulation A against placebo and Formulation A against standard bupivacaine HCl were 1.894 (CI: 0.693; 5.177, p-value: 0.213) and 1.240 (CI: 0.457; 3.366, p-value 0.673) on Day 1 (afternoon) and 2.654 (CI: 0.948; 7.428, p-value: 0.063) and 1.137 (CI: 0.419; 3.089, p-value 0.801) on Day 2 (afternoon).

There were also no statistically significant differences between the treatment groups in the number of patients who had returned to work after 14 days. The odds ratio for the pair-wise comparisons of Formulation A against placebo and Formulation A against standard bupivacaine HCl were 1.210 (CI: 0.325; 4.498, p-value: 0.776) and 1.505 (CI: 0.358; 6.329, p-value 0.577) on Day 14.

Pharmacokinetics

Total and free (unbound) bupivacaine plasma concentrations in patients undergoing arthroscopic subacromial decompression were measured following either administration of 5.0 mL Formulation A (660 mg bupivacaine) or administration of 20 mL standard bupivacaine HCl (50 mg bupivacaine). Using non-compartmental methods the following PK parameters were calculated from the plasma concentrations of each compound: area under the plasma concentration vs. time curve until the last measured concentration (AUC_(t)), area under the plasma concentration vs. time curve extrapolated until infinity (AUC_(inf)), the maximum concentration (C_(max)), the time of its occurrence (t_(max)) and the apparent terminal elimination half-life (t_(1/2)). Due to the extended release characteristics of the Formulation A, bupivacaine plasma concentrations increased relatively slowly and extended profiles of both total and free bupivacaine were observed. At 96 h post dose there are still measureable plasma concentrations in most patients of the Formulation A group. Bupivacaine HCl plasma concentrations were considerably lower than in the Formulation A group at all timepoints. The average plasma protein binding of bupivacaine was approximately 5.2%; free bupivacaine plasma concentrations generally paralleled those of total bupivacaine. There was a large interindividual variability of C_(max) of both total and free bupivacaine. The highest individual C_(max)-values of total and free bupivacaine were 1.320 mg/L and 0.074 mg/L, respectively. Note: Table 1.5 presents Geometric mean, ±68^(th) percentile for C_(max) rather than absolute min,max.

Mean C_(max) and AUC of bupivacaine in the current study were considerably lower than expected from historic studies. A variable amount of the administered dose may have escaped from the wound between administration and closure of the wound, possibly leading to a significantly reduced exposure to bupivacaine.

There was no apparent influence of either total or free bupivacaine on any cardiovascular parameters (QTcF, QTcB and QRS) even at the highest observed bupivacaine plasma concentrations. The few reported CNS side effects did not correlate with either C_(max) or t_(max) of free bupivacaine. Geometric mean total and free bupivacaine plasma concentration following bupivacaine concentration following Formulation A or standard bupivicane are presented in FIG. 2.

FIG. 3 shows a correlation of all individual plasma concentrations of free versus total bupivacaine for Formulation A. Free bupivacaine plasma concentrations increase in proportion with total bupivacaine concentrations. The slope of the regression line indicates the average free fraction (5.2%) over all timepoints and all patients. The plot also shows a high interindividual variability of the free fraction of bupivacaine, which means that high total bupivacaine concentrations do not necessarily imply high free bupivacaine concentrations and vice versa. A summary of the plasma PK-parameters of total and free bupivacaine following Formulation A or standard bupivacaine is presented in Table 1.5.

TABLE 1.5 Plasma PK-parameters of total and free bupivacaine following administration of Formulation A or standard bupivacaine HCl: Standard Standard PK-parameter bupivacaine bupivacaine Mean Formulation A Formulation A HCl HCl (min, max) (total) (free) (total) (free) t_(1/2) 16.4 15.8 5.93 6.65 [h] (8.4, 29) (5.9, 35) (2.6, 9.6) (2.9, 15.2) t_(max) median 5.94 4.00 1.03 1.03 [h] (0, 24) (1.0, 24.0) (0.92, 12.0) (0.92, 12.0) C_(max) 593 36.3 90 5.0 [ng/mL] (70, 1320) (2.5, 74) (8, 195) (0.3, 10.1) AUC_(t) 14.98 0.795 0.686 0.033 [mg · h · L⁻¹] (6.47, 34.69) (0.323, 1.96) (0.249, 1.90) (0.010, 0.102) AUC_(inf) 19395 1045 940 48 [h · ng/mL] (1030, 55370) (44, 2306) (30, 2210) (0.7, 134)

Safety

There were no deaths in the trial and six patients experienced one SAE (one pregnancy case was reported as SAE). One SAE (pulmonary arterial hypertension, reported 113 days after treatment with Formulation A) was considered related to trial drug. Overall, 37 patients (34.6%) experienced at least one TEAE (65 TEAEs were reported in total), of which the majority were of mild or moderate intensity. Nine patients (8.4%) reported TEAEs that were considered to be related to treatment with no notable differences between treatment groups. The most commonly reported TEAEs (see Table 1.6) were within the following System Organ Classes (SOCs): Nervous system disorders; Investigations; and Gastrointestinal disorders. The most commonly reported events (by preferred term) were nausea, headache and musculoskeletal pain (4.7% of patients for each). No patients withdrew due to a TEAE. Between Day 0 and Day 3, three patients in the safety population reported six CNS TEAEs.

The majority of patients in each treatment group had haematology and clinical chemistry parameter values that were either normal or were abnormal but not clinically significant throughout the trial. Clinically significant clinical chemistry abnormalities were reported for four patients (two in the placebo group and one each in the Formulation A and standard bupivacaine HCl groups); the vast majority of increases or decreases were in line with what could be expected after the surgical insult performed. They were assessed to be of no major safety concern.

There were no important differences in the mean and median blood pressure and heart rate on any day from screening to Day 7. There was no significant effect of Formulation A on ECG parameters.

Surgical site healing and/or local tissue conditions were as expected in all patients examined at Day 7, at EOT and at the 6-month follow-up visit. No patients were recorded as experiencing unexpected surgical site healing throughout the trial.

For the vast majority of patients analysed, MRI results from the MRI scan performed at the 6-month follow-up reflected changes from baseline that were consistent with either the surgical procedure insult injection; there were no notable differences between the Formulation A and standard bupivacaine groups.

TABLE 1.6 Summary of TEAEs by primary SOC (>2% total), preferred term and treatment group (safety population) Standard Formulation A Placebo Bupivacaine Primary 5 ml. 5 mL HCl SOC N = 53 N = 25 N = 29 Preferred term n % n % n % All TEAEs 16 30.2 10 40.0 11 37.9 Nervous system disorders 5 9.4 2 8.0 4 13.8 Headache 3 5.7 1 4.0 1 3.4 Investigations 5 9.4 2 8.0 2 6.9 Alanine aminotransferase increased 1 1.9 2 8.0 0 0.0 Gastrointestinal disorders 2 3.8 3 12.0 1 3.4 Nausea 1 1.9 3 12.0 1 3.4 Cardiac disorders 1 1.9 2 8.0 3 10.3 Musculoskeletal and connective tissue disorders 3 5.7 1 4.0 2 6.9 Musculoskeletal pain 2 3.8 1 4.0 2 6.9 Skin and subcutaneous tissue disorders 2 3.8 2 8.0 2 6.9 Injury, poisoning and procedural complications 3 5.7 1 4.0 0 0.0 General disorders and administration site 1 1.9 2 8.0 0 0.0 conditions Respiratory, thoracic and mediastinal disorders 1 1.9 0 0.0 2 6.9 Primary SOCs are presented in descending frequency. Preferred terms are sorted within primary SOC in descending total frequency, based on MedDRA. A patient with multiple occurrences of a TEAE under one treatment was counted only once in the preferred term for that treatment. A patient with multiple TEAEs within a primary SOC was counted only once in the total row. MedDRA = Medical dictionary for regulatory activities; N = number of patients in a treatment group; n = number of patients with at least one event in the category; % = percentage of patients with at least one event in the category based on N; SOC = system organ class; TEAE = treatment-emergent adverse event.

Conclusions

Efficacy

-   -   Superiority of Formulation A to placebo was shown for mean PI on         movement 1 to 72 hours post-surgery. Superiority over standard         bupivacaine HCl was not met.     -   The total use of rescue analgesia at 0 to 72 hours for the         Formulation A treatment group was statistically superior to         placebo but not for standard bupivacaine HCl. The lack of         statistical significance over bupivacaine HCl may have been a         result of the small size of the study and the effects of         background and rescue analgesia. Subjects in the bupivacaine HCl         group used twice as much (based on median amount) opioid rescue         medication as those in the Formulation A group.     -   Overall Formulation A demonstrated analgesic and opioid-sparing         effects against placebo.     -   Secondary efficacy endpoints, with the exception of PI at rest 1         to 72 hours postsurgery, did not reach statistical significance.         Secondary efficacy analyses supported the results of the primary         endpoint analyses.

Pharmacokinetics

-   -   PK-profiles supported the extended release characteristics of         the Formulation A providing long-lasting plasma concentrations         with a median Tmax of approximately 6 hours post dose. In         contrast, plasma concentrations following standard bupivacaine         were considerably lower than in the Formulation A at all         timepoints. The average percentage of unbound bupivacaine was         similar to the values known from literature for comparable         studies.     -   The highest individual plasma concentrations of total and free         bupivacaine were considerably lower than reported concentrations         for the onset of potential CNS and/or cardiovascular         side-effects. AAG plasma concentrations increased as expected         post surgery, causing a slight decrease in the percentage of         unbound bupivacaine.     -   There was no apparent influence of either total or free         bupivacaine on any cardiovascular parameters (QTcF, QTcB and         QRS) even at the highest observed bupivacaine plasma         concentrations.

Safety

-   -   The incidence and severity of treatment-emergent adverse events         were similar for all treatment groups, and no functional or         radiographic differences were noted at 6-month follow-up.     -   Formulation A was safe and well-tolerated, with no long-term         safety signals observed at 6-month follow-up.     -   There were no deaths and the incidence of SAEs in this trial was         low; one SAE was considered related to trial drug (in the         Formulation A group).     -   In terms of systemic safety, Formulation A, standard bupivacaine         HCl and placebo were generally safe and well tolerated. There         were no notable differences between treatment groups regarding         bupivacaine-related side effects. This suggests that         concentrations of free bupivacaine remained below or at the low         end of reported CNS toxicity threshold levels. Additionally, the         reported CNS side effects did not correlate with either C_(max)         or t_(max) of free bupivacaine.     -   There was no effect of Formulation A on ECG parameters.     -   There were no clinically meaningful differences between         treatment groups regarding changes in the shoulder functionality         test (Constant-Murley score) from baseline to 6 months         follow-up.     -   There were no differences between treatment groups regarding         wound healing and local tissue conditions.

Example 2

A clinical trial was conducted to explore therapeutic benefits of 5.0 mL Formulation A administered into the subacromial space in patients undergoing arthroscopic subacromial decompression. This trial further investigated systemic and local safety of Formulation A as compared to placebo in patients who will receive analgesic supplementation as needed with oral opioids per common clinical practice.

Objectives

Primary objective—Explore analgesic effectiveness and characterize the safety profile of Formulation A in an orthopedic surgical model compared to placebo.

Secondary objective—Explore the reduction in frequency of opioid-related adverse events (AEs) by Formulation A in an orthopedic surgical model compared to placebo.

Methods

The study was a randomized, double-blind, multi-center, placebo-controlled, parallel-group trial of a single dose of 5.0 mL Formulation A in subjects undergoing arthroscopic shoulder surgery. Subjects were assessed for pain and supplemental analgesia recorded (efficacy endpoints) and AEs, surgical site healing, local tissue condition, laboratory tests, physical examination and vital signs (safety endpoints).

Composition: Formulation A Active ingredient: Bupivacaine base Inactive ingredients: Sucrose acetate isobutyrate, benzyl alcohol Administration: Varied, based on surgical procedure, interstitial (FDA Code 088) either by tissue infiltration, injection or needle-free deposition for general surgical applications. Strength: 132 mg/mL, 660 mg bupivacaine

Composition Placebo Active ingredient: Not applicable Inactive ingredients: Sucrose acetate isobytyrate, benzyl alcohol Administration: Varied, based on surgical procedure, interstitial (FDA Code 088) either by tissue infiltration, injection or needle-free deposition for general surgical applications. Number of subjects: 60 subjects were enrolled in the study. All 60 subjects enrolled in the study received at least part of a dose of Formulation A or placebo and have been included in the Modified Intent To Treat (MITT) population and the Safety Population. Fifty eight subjects were included in the Per-Protocol Population (subjects that received a complete administration of Formulation A or placebo, met surgical and anesthesia requirements, successfully underwent the surgical procedure and had at least one post-dose pain intensity recorded). Diagnosis and criteria for inclusion: Male and female subjects, aged 18 to 65 years with clinical syndrome of subacromial impingement and scheduled for arthroscopic shoulder surgery; with American Society of Anesthesiologists (ASA) Physical Status Classification of P1 or P2 based on medical history, physical exam, 12 lead electrocardiogram (ECG) and laboratory tests; systolic blood pressure ≤139 mmHg and diastolic blood pressure ≤89 mmHg; willing to use medically acceptable method of contraception, and to refrain from strenuous activities and provide written consent were eligible to participate in the study. Exclusion Criteria: Subjects with glenohumeral arthritis; major or full thickness rotator cuff tears diagnosed by Magnetic Resonance Imaging (MRI); prior arthroscopic surgery or open surgery on the study shoulder; chronic pain conditions requiring continuous use of corticosteroids for >three months; fibromyalgia; rheumatoid arthritis; sero-negative inflammatory athropathies; calculated creatinine clearance <30 mL/min; pregnant or lactating; receiving more than 20 mg of hydrocodone daily (or equivalent) for three or more days within seven days of surgery; opioid tolerance; required use of non-steroidal anti-inflammatory drugs (NSAIDs) within 24 hours of surgery; regular use of anticonvulsants, antiepileptics, antidepressants, or monoamine oxidase inhibitors; regular use of drugs known to prolong QTc interval within seven days of surgery or five times the drugs half life whichever was longer; known hypersensitivity to local anesthetic agents of the amide type or morphine or other opioids; conditions contraindicated for use of opioids; known or suspected abuse of opioids, illicit drugs or alcohol abuse; participation in another trial within 30 days of surgery; not suitable according to the Investigator Surgical Requirements: The subject was not to receive Investigational Product if the following requirements were not met: index procedure was subacromonial decompression performed arthroscopically; other procedures included inspection of glenohumeral joint, synovectomy, removal or loose body, minor debridement of articular cartilage, minor debridement or minor repair of rotator cuff, distal clavicle excision, bursectomy, resection of coracoacromial ligament and subacromial spurs; any conduit between the subacromial space and glenohumeral joint that would allow seepage and entrapment of the Investigational Product in the joint capsule were to be avoided; procedures for shoulder instability were not allowed; biceptal tenodesis or tenotomy were not allowed. Anesthesia Requirements: The arthroscopic shoulder surgery was performed under general anesthesia with propofol induction using intravenous (IV) fentanyl or equivalent; use of local anesthetics for wound perfusion or nerve blocks during the shoulder surgery was not allowed; use of NSAIDS during the shoulder surgery was not allowed; epinephrine could be used in perfusion solution for reduction of bleeding; short-acting opioids used during general anesthesia were not restricted, post-operative opioids given prophylactically for pain were not allowed; antiemetic medications used for general anesthesia were not restricted, post-operative antiemetic medications were not given prophylactically. Formulation A: Single dose of 5.0 mL Formulation A (132 mg/mL, 660 mg bupivacaine) injected into the subacromial space on completion of arthroscopic shoulder surgery. The formulation includes 3 components (sucrose acetate isobutyrate 66 wt %, benzyl alcohol 22.0 wt %, and bupivacaine base 12.0 wt %) that are administered together as a sterile solution. Reference therapy, dose and mode of administration: Single dose of 5.0 mL placebo composition was injected into the subacromial space on completion of arthroscopic shoulder surgery Duration of Treatment: The study was expected to be approximately 4 weeks in duration per subject. This comprised; a 14 day screening period, a single dose administration on the day of surgery, and a follow-up period of 14 days.

Criteria for Evaluation:

Assessment for efficacy: Shoulder pain intensity ‘on movement’; Use of supplemental analgesia for post-operative pain relief.

Assessment of safety: Frequency and severity of AEs; surgical site healing and local tissue condition evaluation; Laboratory tests (chemistry, hematology and urinalysis); Physical examination, ECGs and vital signs.

Statistical Methods:

Randomization: Patients will be randomized (2-to-1 ratio) to Formulation A or Placebo.

Co-Primary Efficacy Endpoints:

Mean Pain Intensity on Movement Area Under the Curve (AUC) normalized over the time period 0 to 72 hours post-dose and Mean total IV morphine-equivalent dose during the period 0 to 72 hours post-dose.

Results Efficacy Results: Pain Intensity Normalized AUC Over 0-72 Hours Post-Dose

Pain intensity normalized AUC over 0-72 hours was compared between treatment groups using ANCOVA with treatment group and trial site as factors and age as a covariate. Although not statistically significant, there was a trend towards the Formulation A group in pain intensity normalized AUC over 0-72 hours. The LS means were 5.33 for the Formulation A group and 5.97 for the placebo group. The pain scores in the Formulation A group were consistently lower than in the placebo group the mean difference between the groups being most prominent in the first 24 hours (Table 2.1 below).

TABLE 2.1 Pain Intensity Normalized AUC over Scheduled Assessments by Treatment (MITT Subjects Set) Difference in Least-Squares Formulation A Placebo Means (Active- Means¹ (n = 40) (n = 20) Placebo) AUC 0-24 hours 5.56 6.38 −0.81 AUC 0-36 hours 5.72 6.38 −0.66 AUC 0-48 hours 5.62 6.30 −0.67 AUC 0-72 hours 5.33 5.97 −0.64 AUC 0-96 hours 5.07 5.62 −0.55 AUC 0-last hours 4.04 4.27 −0.23 AUC 24-48 hours 5.59 6.27 −0.68 AUC 36-72 hours 4.77 5.34 −0.57 AUC 48-72 hours 4.72 5.27 −0.55 AUC 72-96 hours 4.31 4.62 −0.31 ¹Least-Squares Means estimated using an ANOVA model with treatment group and study site as factors

Cumulative IV Morphine-Equivalent Dose Over 0-72 Hours Post-Dose

Opioid rescue analgesia cumulative IV morphine equivalent dose is presented by treatment in Table 2.2 below. Cumulative morphine equivalent dose over 0-72 hours was compared between treatment groups using ANCOVA with treatment group and trial site as factors and age as a covariate. Although not statistically significant, there was a trend towards the 5.0 mL Formulation A group in cumulative IV morphine equivalent dose over 0-72 hours. The LS mean were 44.27 for the 5.0 mL Formulation A group and 54.51 for the placebo group.

TABLE 2.2 Opioid Rescue Analgesia Cumulative IV Morphine Equivalent Dose (mg) by Treatment (MITT Subjects Set) Difference in Least-Squares Formulation Placebo Means (Active- Means¹ A (n = 40) (n = 20) Placebo) Day 0-Day 2 (0-48 Hours) 36.47 47.21 −10.74 Day 0-Day 3 (0-72 Hours) 44.27 54.51 −10.25 Day 0-Day 14 69.13 77.91 −8.77  0-24 Hours 24.19 35.37 −11.18 24-48 Hours 12.35 12.51 −0.16 48-72 Hours 7.77 7.60 0.17 ¹Least-Squares Means estimated using an ANOVA model with treatment group and study site as factors

For the secondary study endpoints, pain intensity on movement normalized AUC (0-48 hours), mean total IVmorphine equivalent opioid dose (0-48 hours) and time to first opioid dose, was observed between the two treatment groups. There was a trend towards the 5.0 mL Formulation A group in pain intensity normalized AUC over 0-48 hours. The cumulative morphine equivalent dose over 0-24 hours, 0-48 hours, Days 0-14, and 24-48 hours hours showed a trend towards the 5.0 mL Formulation A group for all timepoints.

Pain Intensity on Movement

Analyses were performed for pain intensity normalized AUC over 0-48 hours, 0-last hours, 0-24 hours, 0-36 hours, 0-96 hours, 24-48 hours, 36-72 hours, 48-72 hours and 72-96 hours. Pain intensity normalized AUC was compared between treatment groups using ANCOVA with treatment group and trial site as factors and age as a covariate (FIG. 4). Although not statistically significant, there is a trend towards the 5.0 mL Formulation A group in pain intensity normalized AUC for all time points. For the MITT Subjects Set, at all time points, the LS means were lower for the 5.0 mL Formulation A group than the placebo group. FIG. 5A depicts the mean pain intensity on movement by subjects in the MITT set administered Formulation A as compared to subjects administered placebo at time points post dose. FIG. 5B depicts the mean pain intensity on movement by subjects in the PP set administered Formulation A as compared to subjects administered placebo at time points post dose.

Cumulative Morphine Equivalent Dose

Analyses were performed for cumulative morphine equivalent dose over 0-48 hours, Days 0-14, 0-24 hours, 24-48 hours and 48-72 hours. Cumulative morphine equivalent dose was compared between treatment groups using ANCOVA with treatment group and trial site as factors and age as a covariate (FIG. 6). Although not statistically significant, there was a trend towards the 5.0 mL Formulation A group in cumulative morphine equivalent dose for all time points.

For the MITT Subjects Set, apart from 48-72 hours, at all other time points, the LS means were lower for the 5.0 mL Formulation A group than the placebo group. For the PP Subjects Set, the LS means were lower for the 5.0 mL Formulation A group than the placebo group for 0-72 hours, 0-48 hours and 0-24 hours.

Time to First Opioid Use

Time to first opioid use was analyzed using a log-rank test to compare the two treatment groups. The median time to first opioid use for the MITT Subjects Set (0.43 hours for Formulation A 5.0 mL compared to 0.48 hours for placebo) and the PP Subjects Set (0.42 hours for Formulation A 5.0 mL compared to 0.50 hours for placebo) was not statistically significant. FIG. 7 depicts the cumulative morphine equivalent dose in the MITT set administered Formulation A as compared to subjects administered placebo at time points post dose.

Efficacy Conclusions

For the primary study endpoints, although statistically significant treatment effects were not seen in this study, there were indications of reduction of pain scores and opioid use in the 5.0 mL Formulation A group compared to placebo. The LS mean pain intensity on movement AUC over 0 to 72 hours post-dose was 5.33 in the 5.0 mL Formulation A group compared to 5.97 for placebo. This difference was lower than the estimated value used in the sample size calculation (an observed mean difference of 0.64 compared to an estimated mean of 1.9). The inferential aspects of the statistical analysis however, were not of primary importance in this study as the study was intended to be of an exploratory nature. The difference in cumulative morphine equivalent dose between the treatment groups was not statistically significant. LS mean cumulative morphine equivalent dose over 0 to 72 hours was 44.27 in the 5.0 mL Formulation A group compared to 54.51 in the placebo group. For both primary endpoints, the differences compared to placebo were most prominent during the first 6-10 hours post-surgery.

For the secondary study endpoints, pain intensity on movement normalized AUC (0-48 hours), mean total morphine equivalent opioid dose (0-48 hours) and time to first opioid dose, no statistically significant differences were observed between the two treatment groups. There was a trend towards the 5.0 mL Formulation A group in pain intensity normalized AUC over 0-48 hours. The cumulative morphine equivalent dose over 0-24 hours, 0-48 hours, Days 0-14, 24-48 hours and 48-72 hours were not statistically significant, although there was a trend towards the 5.0 mL Formulation A group for all timepoints. The median time to first opioid use was not statistically significant.

Safety Results:

All 60 subjects received at least part of their allocated treatment and were included in the safety analysis. Equal proportions of subjects experienced at least one AE—38 (95.0%) subjects in the 5.0 mL Formulation A group and 19 (95.0%) subjects in the placebo group. Seventeen (42.5%) subjects in the 5.0 mL Formulation A group experienced at least one AE with a maximum relationship of related, compared with seven (35.0%) subjects in the placebo group. Most AEs were either mild or moderate in intensity. Eight (20.0%) subjects in the 5.0 mL Formulation A group experienced at least one AE with a maximum severity of severe, compared with 5 (25.0%) subjects in the placebo group. The severity of TEAEs reported was similar between the two treatment groups. The most common AEs in the 5.0 mL Formulation A group were constipation, nausea, vomiting, dizziness, paraesthesia and somnolence. In the placebo group, the most common AEs were constipation, nausea, dizziness and somnolence. In general, the TEAEs expressed with high frequency were similar between the two treatment groups. There were no statistically significant differences or trends in frequency of opioid related TEAEs (constipation, dizziness, drowsiness, nausea, respiratory depression, urinary retention, or vomiting) at any time point in the study. Only one SAE was reported during the study. The event was pyrexia and was reported by subject 03-007 in the 5.0 mL Formulation A group. The event was considered to be mild and unlikely to be related to study drug. Administration of 5.0 mL Formulation A was safe and well tolerated based on review of hematology, biochemistry and urinalysis data, vital sign assessment, and evaluation of physical examination findings and concomitant medication use. All subjects had surgical site healing and local tissue condition at Day 14 as expected. TEAEs by system, organ, class and preferred term are summarized by system organ class in Table 2.3 below.

TABLE 2.3 TEAEs by System, Organ, Class 5 mL Formulation A Placebo (N = 40) (N = 20) System Organ Class n % n % Number of subjects with at 38 (95.0) 19 (95.0) least one TEAE Ear And Labyrinth Disorders 8 (20.0) 1 (5.0) Eye Disorders 1 (2.5) 0 (0.0) Gastrointestinal Disorders 32 (80.0) 17 (85.0) General Disorders And 7 (17.5) 2 (10.0) Administration Site Conditions Infections And Infestations 1 (2.5) 1 (5.0) Injury, Poisoning 6 (15.0) 2 (10.0) And Procedural Complications Investigations 4 (10.0) 2 (10.0) Metabolism And Nutrition Disorders 0 (0.0) 1 (5.0) Musculoskeletal And 6 (15.0) 1 (5.0) Connective Tissue Disorders Nervous System Disorders 33 (82.5) 18 (90.0) Psychiatric Disorders 1 (2.5) 1 (5.0) Renal And Urinary Disorders 9 (22.5) 4 (20.0) Reproductive System And 1 (2.5) 0 (0.0) Breast Disorders Respiratory, Thoracic 7 (17.5) 2 (10.0) And Mediastinal Disorders Skin And Subcutaneous 8 (20.0) 2 (10.0) Tissue Disorders

A summary of TEAEs experienced by >7.5% of subjects, by preferred term and treatment group is presented in Table 2.4 below. 7.5% was selected to review frequency of TEAEs as this included TEAEs experienced by at least two subjects in the smaller treatment group. The most common AEs in the 5.0 mL Formulation A group were constipation, nausea, vomiting, dizziness, paraesthesia and somnolence. In the placebo group, the most common AEs were constipation, nausea, dizziness and somnolence. In general, the TEAEs expressed with high frequency were similar between the two treatment groups.

TABLE 2.4 TEAEs with Frequency >7.5% by Treatment Group 5 mL Formulation A Placebo (N = 40) (N = 20) Preferred Term n % n % Somnolence 29 (72.5) 16 (80.0) Nausea 26 (65.0) 15 (75.0) Constipation 18 (45.0) 10 (50.0) Vomiting 14 (35.0) 4 (20.0) Dizziness 14 (35.0) 7 (35.0) Paraesthesia 9 (22.5) 2 (10.0) Dysuria 8 (20.0) 4 (20.0) Pruritus 8 (20.0) 2 (10.0) Hypoaesthesia 7 (17.5) 3 (15.0) Tinnitus 6 (15.0) 1 (5.0) Dysgeusia 5 (12.5) 1 (5.0) Headache 5 (12.5) 4 (20.0) Dry Mouth 4 (10.0) 2 (10.0) Pyrexia 4 (10.0) 1 (5.0) Muscle Twitching 3 (7.5) 0 (0.0) Dyspnoea 3 (7.5) 0 (0.0) Pharyngolaryngeal Pain 3 (7.5) 1 (5.0)

Conclusion

The efficacy data in this study showed a consistent reduction of pain scores (as measured by mean pain intensity on movement AUC, time normalized under the curve, during the period 0 to 72 hours post-surgery) in subjects randomized to receive 5.0 mL Formulation A compared to placebo. There was also a reduction of opioid use (as measured by the amount of opioids taken in the three days post-surgery) in subjects randomized to receive 5.0 mL Formulation A compared to placebo. These reductions were not statistically significant. The findings related to pain scores and opioid use were most prominent during the first 6-10 hours post-surgery. The incidence of AEs, vital signs and laboratory abnormalities indicate that administration of 5.0 mL Formulation A is safe, and the lack of withdrawals and mild nature of AEs indicate that administration of 5.0 mL Formulation A is well tolerated in this patient population.

Example 3

A clinical trial was conducted to study the administration of a bupivacaine composition into the subacromial space in patients undergoing arthroscopic subacromial decompression. The study further investigated systemic and local safety of the bupivacaine composition as compared to placebo in patients.

The bupivacaine composition (Formulation A) used in these studies is a clear, light yellow to brown liquid, intended for use as a postsurgical analgesic after a variety of surgical procedures. The bupivacaine composition contains bupivacaine base in a sustained-release matrix comprised of a fully esterified sugar derivative. In this study, the intent of Formulation A is to provide effective postoperative local analgesia by providing sustained local release of bupivacaine over a period of several days. The formulation includes 3 components (sucrose acetate isobutyrate 66 wt %, benzyl alcohol 22.0 wt %, and bupivacaine base 12.0 wt %) that are administered together as a sterile solution.

Composition: Formulation A Active ingredient: Bupivacaine base Inactive ingredients: Sucrose acetate isobutyrate, benzyl alcohol Administration: Varied, based on surgical procedure, interstitial (FDA Code 088) either by tissue infiltration, injection or needle-free deposition for general surgical applications. Strength: 132 mg/mL, 660 mg bupivacaine

Composition Placebo Active ingredient: Not applicable Inactive ingredients: Sucrose acetate isobytyrate, benzyl alcohol Administration: Varied, based on surgical procedure, interstitial (FDA Code 088) either by tissue infiltration, injection or needle-free deposition for general surgical applications.

Objectives

Primary objective—To determine the efficacy of Formulation A (bupivacaine, benzyl alcohol, sucrose acetate isobutyrate) administered subcutaneously or into the subacromial space in subjects undergoing elective arthroscopic shoulder surgery involving subacromial decompression.

Secondary objective—To determine the safety and tolerability of Formulation A (bupivacaine, benzyl alcohol, sucrose acetate isobutyrate) administered subcutaneously or into the subacromial space in subjects undergoing arthroscopic shoulder surgery involving subacromial decompression.

Study objectives were defined specifically for each of Cohort 1 and Cohort 2.

Methods

The study was a randomized, double-blind, placebo-controlled study of the efficacy and safety of subcutaneous or subacromial bupivacaine in patients undergoing rotator cuff repair and to assess the safety and tolerability of Formulation A (bupivacaine, benzyl alcohol, sucrose acetate isobutyrate) as a delivery system. Surgery in all subjects was performed under local or general anesthesia according to standard local practice.

The study was conducted in 2 separate and sequential cohorts (Cohort 1 and Cohort 2). Approximately equal numbers of subjects were to be enrolled, in sequence, to each cohort. The study duration was up to 21 days including screening, admission to clinic and surgery (Day 0), postoperative evaluations, discharge from clinic, and follow-up through Day 14.

The subjects were evaluated on Days 1 and 2 in the clinic or at home, on Day 3 in the clinic, and on Days 4 through 7 by telephone following surgery and treatment. Subjects returned on Day 14 for follow-up evaluation and plasma collection. Subjects recorded pain intensity (PI), concomitant medications, adverse events (AEs), and rescue analgesia on diary cards from Day 0 through Day 7. Subjects also recorded AEs and concomitant medications through Day 14.

Cohort 1:

Immediately prior to surgery 45 subjects were randomly assigned in a 1:1:1 ratio (Treatment Group 1, Treatment Group 2, Treatment Group 3) to receive 1 of the following treatments:

Treatment Group 1: Prior to wound closure, 5.0 mL of placebo composition was injected into the subacromial space. After wound closure, a total volume of 5.0 mL of Formulation A was administered as 2 trailing subcutaneous injections along each side of the incision line. The total amount of bupivacaine was 660 mg.

Treatment Group 2: Prior to wound closure, 5.0 mL of Formulation A was injected into the subacromial space. After wound closure, a total volume of 5.0 mL of placebo composition was administered as 2 trailing subcutaneous injections along each side of the incision line. The total amount of bupivacaine was 660 mg.

Treatment Group 3: Prior to wound closure, 5.0 mL of placebo composition was injected into the subacromial space. After wound closure, a total volume of 5.0 mL of placebo composition was administered as 2 trailing subcutaneous injections along each side of the incision line. (The total delivered volume of placebo composition was 10.0 mL.)

For all treatment groups if the procedure was performed arthroscopically, the subcutaneous doses of study drug were administered evenly around all arthroscopic portals.

Cohort 2:

Upon completion of Cohort 1, enrollment of subjects into Cohort 2 was started. Immediately prior to surgery, 45 subjects were randomly assigned in a 1:1 enrollment ratio (Treatment Group 4 and Treatment Group 5) to receive 1 of the following treatments:

Treatment Group 4: During wound closure, 5.0 mL of placebo composition was injected into the subacromial space.

Treatment Group 5: During wound closure, 5.0 mL of Formulation A was injected into the subacromial space

During the study, the amount of drug to be administered in Cohort 2 was changed from 7.5 mL (990 mg bupivacaine) to 5.0 mL (660 mg bupivacaine). However, 4 subjects were administered Treatment 4a (7.5 mL placebo composition) and 3 subjects were administered Treatment 5a (7.5 mL Formulation A)

Nine subjects were randomized to receive placebo composition or 5.0 mL Formulation A at 1 participating center in order to obtain PK (pharmacokinetic) measurements in the double-blind portion of the study. Of these 9 subjects, 4 received 5.0 mL Formulation A and 5 received placebo composition. Upon completion of the double-blind portion of the study, a supplemental PK sub-study protocol was implemented to enroll up to 14 additional PK subjects to receive 5.0 mL open-label Formulation A subacromially. The overall PK results for the 18 PK subjects who received 5.0 mL Formulation A is discussed in greater detail below.

Preparation of Study Drug for Administration:

The study drug was administered with 5 mL syringes which were used to withdraw 5.0 mL of study drug from 10.0 mL vials of either Formulation A or Placebo Composition.

Postoperative Rescue Analgesia

Postoperative rescue analgesia was to be prescribed on request. The time, name, and dose of all rescue analgesics were recorded throughout the study period by all subjects on either paper or electronic diaries. Distinction was made between those analgesics taken for surgical wound pain and those taken for other indications. A pain intensity (PI) evaluation was completed immediately prior to each time rescue analgesic medication was requested by a subject.

Subject Criteria

Number of subjects: The planned enrollment was 90 subjects in order to ensure at least 72 evaluable subjects (approximately 36 subjects in each cohort, 12 subjects in each treatment group of Cohort 1 and 18 in each treatment group of Cohort 2). A total of 40 subjects were enrolled in Cohort 1; 14 to Treatment 1, 10 to Treatment 2, and 16 to Treatment 3. All 40 subjects completed Cohort 1. A total of 52 subjects were enrolled in Cohort 2; 4 to Treatment 4a, 24 to Treatment 4, 3 to Treatment 5a, and 21 to Treatment 5. Fifty subjects completed Cohort 2; 1 subject in Treatment 4 and 1 subject in Treatment 5a voluntarily withdrew.

Upon completion of the double-blind portion of the study, a supplemental PK sub-study protocol was implemented which enrolled 14 additional PK subjects to receive 5.0 mL open-label Formulation A subacromially.

Diagnosis and main criteria for inclusion: Males and females, 18 years of age and older who underwent elective rotator cuff repair, were in good general health, and met all the inclusion and exclusion criteria, were eligible to participate in the study.

Duration of treatment: Subjects received a single dose of study drug. The study duration was up to 21 days comprising screening, admission to clinic and surgery (Day 0), postoperative evaluations, discharge from clinic, and follow-up through Day 14.

Criteria for Evaluation:

Efficacy:

Efficacy was assessed using the subjects' self-evaluation of PI and pain control collected on subject diaries (Days 0 to 7), the Modified Brief Pain Inventory (Days 1 to 7), and the subjects' use of concomitant rescue analgesic medication (Days 0 to 14).

The primary efficacy endpoints were PI on movement, PI at rest, and pain control poor (1), fair (2), good (3), very good (4), excellent (5) collected on Days 0 through Day 7. The secondary efficacy endpoints were worst and least pain scores, rescue analgesia usage, function, overall treatment satisfaction, and individual PI over time.

Safety:

Safety evaluations included AEs; assessments of laboratory tests such as chemistry, hematology, and urinalysis; a serum pregnancy test (if applicable); periodic monitoring of vital signs; 12 lead electrocardiogram (ECG); concomitant medications; and physical examinations. Evaluations also included surgical site healing and local tissue conditions

Statistical Methods:

Unless otherwise stated, all statistical tests were performed using 2-sided tests at the 5% significance level. No multiplicity adjustment was made for any of the analyses. The per-protocol (PP) population includes all subjects who successfully underwent the surgical procedure, received study drug, and had postoperative data on pain evaluations recorded at 1 or more postoperative time points. Summary tables and statistical analysis of all efficacy endpoints are based on the PP population. Safety summaries are based on the safety population, which includes all randomized subjects who received any amount of study drug. Data was determined for the following treatment groups:

-   -   Treatment 1 (Formulation A subcutaneous)     -   Treatment 2 (Formulation A subacromial)     -   Treatment 5 (Formulation A subacromial)     -   Formulation A (Treatments 2 and 5)     -   Treatment 5a (7.5 mL Formulation A)     -   Pooled Placebo comprising:         -   Treatment 3 (10.0 mL placebo composition)         -   Treatment 4 (5.0 mL placebo composition)         -   Treatment 4a (7.5 mL placebo composition)

The comparison of primary interest was between Treatment 5 and Pooled Placebo. The significance of comparisons between Formulation A, Treatment 2, and Treatment 1 and Pooled Placebo were also determined.

The incidence (number and percentage) of treatment-emergent AEs was determined for each treatment group in accordance with the Medical Dictionary for Regulatory Activities (MedDRA) Version 8.0 system organ class and preferred term. A separate overall incidence was determined on AEs with onset on Day 0. The worst severity of the AEs and their relationship to study medication was also determined.

Separate overall incidence summaries were determined for anticipated events as checked on subject diaries: nausea/vomiting, drowsiness, itching, constipation, dizziness, tinnitus, dysgeusia, and paresthesia.

Specific safety evaluations of the Modified Brief Pain Inventory were tabulated by study day and treatment. Incidence across all study days was also determined by treatment.

Surgical site healing and local tissue condition evaluations were summarized and tabulated by subject incidence (number and percentage) for each treatment group over time.

Abnormal or change from screening physical examination results were determined. Vital signs were listed descriptively for each treatment group at each collection time point. Changes from baseline (predose) vital signs were summarized for each treatment and scheduled interval. Screening and unscheduled ECGs were used.

Results

Efficacy Results:

The primary endpoint PI scores (AUC/120 hours) during movement and at rest are summarized by treatment group in Table 3.1 and Table 3.2 respectively. Mean PI_(move) values in the Formulation A treatment groups were 5.47, 3.27, and 5.12 (Treatments 1, 2, and 5, respectively), compared to 5.22 in the Pooled placebo group. Treatment 2 had the lowest mean value (least pain). The comparison to the Pooled Placebo group demonstrates that Treatment 2 was significantly better than Pooled Placebo (treatment difference=−1.95, 95% CI=−3.59 to −0.31, P=0.02). The Formulation A group was numerically better than Pooled placebo (treatment difference=−1.03, 95% CI=−2.14 to 0.09); this difference did not reach statistical significance (P=0.072). For average PI during rest, Treatment 2, Treatment 5, and Formulation A were numerically better than Pooled placebo; these differences did not reach statistical significance.

TABLE 3.1 Summary of Pain Intensity During Movement Time- weighted Average Scores (AUC/120), PP Population Comparison to Pooled Placebo Treatment n Mean (SD) Mean Difference (95% CI) P-value Treatment 1 14 5.47 (2.352) 0.25 (−1.13-1.62) 0.720 Treatment 2 9 3.27 (1.648) −1.95 (−3.59-−0.31) 0.020 Treatment 5 21 5.12 (2.230) −0.10 (−1.29-1.09) 0.866 Formulation A 30 4.56 (2.219) −1.03 (−2.14-0.09) 0.072 Pooled Placebo 44 5.22 (2.281) Treatments (5.0 mL): 1 = Formulation A Subcutaneous 2 = Formulation A Subacromial 3 = Placebo 4 = Placebo 5 = Formulation A Treatments 4a and 5a are the same as Treatments 4 and 5, but using 7.5 mL Formulation A = Treatments 2 and 5 Pooled placebo = Treatments 3, 4a, and 4

TABLE 3.2 Summary of Pain Intensity During Rest Time-weighted Average Scores (AUC/120), PP Population Comparison to Pooled Placebo Treatment n Mean (SD) Mean Difference (95% CI) P-value Treatment 1 14 3.53 (2.331) 0.43 (−0.76-1.63) 0.473 Treatment 2 9 2.16 (1.496) −0.95 (−2.37-0.48) 0.190 Treatment 5 21 2.58 (1.674) −0.52 (−1.56-0.51) 0.315 Formulation A 30 2.45 (1.609) −0.73 (−1.71-0.24) 0.136 Pooled Placebo 44 3.10 (1.995) Treatments (5.0 mL): 1 = Formulation A Subcutaneous 2 = Formulation A Subacromial 3 = Placebo 4 = Placebo 5 = Formulation A Treatments 4a and 5a are the same as Treatments 4 and 5, but using 7.5 mL Formulation A = Treatments 2 and 5 Pooled placebo = Treatments 3, 4a, and 4 The other primary efficacy variable was pain control by study day and treatment, assessed using the numerical score for the PP Population (1=Poor, 5=Excellent). The average pain control scores for Day 1 through Day 7 are summarized by treatment group in Table 3.3 Statistical comparisons were limited to the Formulation A versus Pooled placebo. The only statistically significant difference observed was on Day 1 (P=0.008) where the Formulation A and Pooled placebo treatment groups had average pain control scores of 3.3 and 2.5, respectively; no statistically significant differences were observed during the rest of the study (Days 2 through 7) for pain control.

TABLE 3.3 Pain Control on Study Days 1 through 7 by Treatment, PP Population Mean Pain Control by Day Treatment Group Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Treatment 1 3.0 2.7 3.1 3.0 3.2 3.1 3.1 Treatment 2 3.3 3.4 3.2 3.4 3.4 3.7 3.8 Treatment 5 3.3 3.4 3.4 3.7 3.6 3.6 3.7 Formulation A 3.3 3.4 3.3 3.6 3.5 3.6 3.7 Pooled Placebo 2.5 3.0 3.4 3.4 3.4 3.4 3.6 P-value (Formulation 0.008 0.111 0.767 0.532 0.608 0.380 0.689 A vs. Pooled Placebo) Treatments (5.0 mL): 1 = Formulation A Subcutaneous 2 = Formulation A Subacromial 3 = Placebo 4 = Placebo 5 = Formulation A Treatments 4a and 5a are the same as Treatments 4 and 5, but using 7.5 mL Formulation A = Treatments 2 and 5 Pooled placebo = Treatments 3, 4a, and 4

The opioid rescue medication, expressed as cumulative IV morphine equivalent doses are summarized in Table 3.4 for Days 0 to 5. Mean values in Formulation A treatment groups for opioid rescue analgesia cumulative morphine equivalent doses were 70.30, 24.96, and 42.74 (Treatments 1, 2, and 5, respectively), compared to 55.27 in the Pooled placebo group. Treatment 2 had the lowest mean value (least cumulative morphine equivalent dose). Compared to the Pooled placebo group, Treatment 2 was numerically better than Pooled placebo; the difference did not reach statistical significance (P=0.147).

TABLE 3.4 Opioid Rescue Analgesia Cumulative (Day 0 through 5) IV Morphine Equivalent Dose (unit/unit) by Treatment, PP Population Comparison to Pooled Placebo Treatment n Mean (SD) P-Value Treatment 1 14 70.30 (62.984) 0.389 Treatment 2 9 24.96 (20.175) 0.147 Treatment 5 21 50.36 (66.102) 0.744 Formulation A 30 42.74 (57.148) 0.216 Pooled Placebo 44 55.27 (55.509) Treatments (5.0 mL): 1 = Formulation A Subcutaneous 2 = Formulation A Subacromial 3 = Placebo 4 = Placebo 5 = Formulation A Treatments 4a and 5a are the same as Treatments 4 and 5, but using 7.5 mL Formulation A = Treatments 2 and 5 Pooled placebo = Treatments 3, 4a, and 4

In Formulation A treatment groups (Treatments 1, 2, and 5), as well as in the Pooled placebo group, all subjects required rescue analgesia.

All of the other secondary endpoints (worst and least pain scores, function, overall treatment satisfaction, and individual PI over time did not show any significant results.

A post hoc analysis of PI over time was conducted for the 2 cohorts separately. In Cohort 1, the Formulation A subacromial treatment group (Treatment 2) had a lower PI on movement compared with the placebo group (Treatment 3) and no difference was observed between the Formulation A subcutaneous treatment group (Treatment 1) and the placebo group (Treatment 3). In Cohort 2, no reduction in PI on movement was observed in the Formulation A subacromial treatment group (Treatment 5) versus placebo (Treatment 4). No differences in opioid rescue analgesia use were observed between the treatment groups in Cohort 1 and Cohort 2.

FIG. 8 shows mean PI_(move) over time, analyzed separately for Cohort 1 and Cohort 2. This Figure demonstrates that for Cohort 1, the average PI on movement score for Treatment 2 (5.0 mL Formulation A subacromial) was lower than the average PI on movement score for placebo (Treatment 3). No difference in PI on movement scores between Treatment 1 (5.0 mL Formulation A subcutaneous) and placebo (Treatment 3) was observed. In Cohort 2, no reduction in PI on movement in Treatment 4 (Formulation A subacromial) versus placebo (Treatment 5) was observed.

A subgroup analysis was performed on subjects from both cohorts who had minimal or no glenohumeral pathology. The difference between the pooled subacromial active treatment groups and the pooled placebo was tested using the pre-specified ANOVA model including study center and treatment group as factors. The mean pain intensity on movement AUC (over the 72-hour period) for active and placebo were 3.6 and 6.1, respectively. The corresponding difference in mean pain intensity on movement AUC (over the 72-hour period, active-placebo) was −2.6 (95% CI: (−4.1, −1.1)). This result is statistically significant (p=0.0012), and supports analgesic benefit in favor of active subacromial treatment representing a 41.8% reduction in pain (while the ITT analysis showed 16.5% reduction).

FIG. 9 shows PI_(move) over time in the subgroup of subjects who had minimal or no glenohumeral pathology. It demonstrates increased analgesia in those treatment groups using subacromial administration of Formulation A (Treatments 2 and 5) compared to placebo (Treatments 3 and 4). Treatment 1, which used subcutaneous administration of Formulation A, did not show a reduction in PI_(move) compared to placebo (Treatments 3 and 4).

The mean total morphine-equivalent dose for active and placebo were 33.5 and 56.9, respectively. The corresponding difference in means between (placebo-active) was 23.4 (95% CI: (−1.1, 47.9)). This result represents a 41.1% reduction in opioid use (while the ITT analysis showed a 16.1%) in favor of active subacromial treatment, but was not statistically significant.

Safety Results:

The overall frequency of AEs was similar between treatment groups. The most commonly reported treatment-emergent AEs were nausea, somnolence, pruritus, and constipation. The majority of treatment-emergent AEs were of mild or moderate severity. There were no deaths or discontinuations due to AEs. One serious AE occurred in treatment group 4 (postprocedural pain), which was severe in intensity and considered unrelated to study drug by the investigator. An analysis of specific safety evaluations of interest did not indicate any opioid-related safety issues.

A summary of treatment-emergent adverse events (TEAE) by treatment is shown in Table 3.5.

TABLE 3.5 Specific Safety Evaluations Observed Over Days 0 to 7 (Safety Population) Pooled Treatment 1 Treatment 2 Treatment 5 Treatment 5a Formulation A Placebo (n = 14) (n = 10) (n = 21) (n = 3) (n = 31) (n = 44) Nausea 11 (78.6%) 7 (70.0%) 14 (66.7%) 3 (100.0%) 20 (64.5%) 34 (77.3%) Vomiting 5 (35.7%) 3 (30.0%) 5 (23.8%) 2 (66.7%) 7 (22.6%) 15 (34.1%) Somnolence 8 (57.1%) 9 (90.0%) 12 (57.1%) 3 (100.0%) 20 (64.5%) 33 (75.0%) Dizziness 10 (71.4%) 5 (50.0%) 11 (52.4%) 3 (100.0%) 15 (48.4%) 22 (50.0%) Tinnitus 4 (28.6%) 2 (20.0%) 2 (9.5%) 1 (33.3%) 3 (9.7%) 7 (15.9%) Pruritus 10 (71.4%) 8 (80.0%) 12 (57.1%) 3 (100.0%) 19 (61.3%) 29 (65.9%) Dysgeusia 6 (42.9%) 3 (30.0%) 6 (28.6%) 1 (33.3%) 8 (25.8%) 13 (29.5%) Paresthesia 5 (35.7%) 2 (20.0%) 4 (19.0%) 2 (66.7%) 5 (16.1%) 12 (27.3%) Constipation 10 (71.4%) 5 (50.0%) 12 (57.1%) 3 (100.0%) 16 (51.6%) 24 (54.5%) Treatments (5.0 mL): 1 = Formulation A Subcutaneous 2 = Formulation A Subacromial 3 = placebo 4 = placebo 5 = Formulation A Treatments 4a and 5a are the same as Treatments 4 and 5, but using 7.5 mL Formulation A = Treatments 2 and 5 Pooled Placebo = Treatments 3, 4a, and 4

Conclusions

Formulation A is an injectable solution specifically formulated to prolong regional postoperative analgesia and is intended for use as a postoperative analgesic after a variety of surgical procedures. Each milliliter of Formulation A contains 12% wt bupivacaine representing 132 mg/mL of bupivacaine. The primary efficacy endpoint of PI move was shown to be significantly better in Treatment 2 (Formulation A Subacromial) compared to the Pooled placebo group (Treatments 3, 4a, and 4), and was not significantly better in Treatment 1 (Formulation A Subcutaneous), Treatment 5 (Formulation A), and Formulation A (Treatments 2 and 5, Formulation A Subacromial and Formulation A, respectively) compared to the Pooled placebo group (Treatments 3, 4a and 4). The results of the post hoc analyses in Cohort 1 showed that the Formulation A subacromial treatment group (Treatment 2) had a lower PI on movement compared with the placebo group (Treatment 3) and no difference was observed between Formulation A subcutaneous treatment group (Treatment 1) and the placebo group (Treatment 3). In the subanalysis performed on subjects from both cohorts who had minimal or no glenohumeral pathology, those treatment groups using subacromial administration of Formulation A (Treatments 2 and 5) had a lower PI on movement compared to placebo (Treatments 3 and 4). Treatment 1, which used subcutaneous administration of Formulation A, did not show a reduction in PI on movement compared to placebo. The overall frequency of AEs was similar between treatment groups.

Example 4 Formulation A for Infiltration Use

Warning: Risk of Potential Adverse Embolic Effects Resulting from Inadvertent Intravascular Injection

Inadvertent intravascular injection could cause Formulation A droplets to be deposited in the pulmonary and other capillary beds. Administer Formulation A into the subacromial space at the end of arthroscopic shoulder surgery. Direct arthroscopic visualization must be used to confirm proper placement of the needle tip before injecting Formulation A.

Indications and Usage

Formulation A contains an amide local anesthetic and is indicated for administration into the subacromial space under direct arthroscopic visualization to produce post-surgical analgesia for up to 72 hours following arthroscopic subacromial decompression.

Limitations of Use

Safety and effectiveness have not been established in other surgical procedures, including soft tissue surgical procedures, other orthopedic procedures, including for intra-articular administration, and boney procedures, or when used for neuraxial or peripheral nerve blockade.

Dosage and Administration

Formulation A is intended in some cases for single dose administration only.

Do not dilute or mix Formulation A with local anesthetics or other drugs or diluents.

Do not convert from other bupivacaine formulations to Formulation A. Do not substitute.

Avoid additional use of local anesthetics within 168 hours following administration of Formulation A.

The recommended dose is 660 mg (5 mL).

Dosage Forms and Strengths

Formulation A (bupivacaine solution) 5 mL single-dose vial, 660 mg/5 mL (132 mg/mL)

Contraindications

Do not use in patients with a known hypersensitivity (e.g., anaphylactic reactions and serious skin reactions) to any amide local anesthetic, or other components of Formulation A.

Do not use in patients undergoing obstetrical paracervical block anesthesia.

Warnings and Precautions

Risk of Joint Cartilage Necrosis with Unapproved Intra-articular Use: A study evaluating the effects of Formulation A and Formulation A vehicle in dogs following an intra-articular administration demonstrated joint cartilage necrosis (5.2, 13.2).

Risk of Systemic Toxicity: Careful and constant monitoring of cardiovascular and respiratory (adequacy of ventilation) vital signs and the patient's state of consciousness should be performed after injection of bupivacaine. (5.3)

Methemoglobinemia: Cases of methemoglobinemia have been reported in association with local anesthetic use. See Full Prescribing Information for more detail on managing these risks. (5.4)

Chondrolysis with Intra-Articular Infusion: Intra-articular infusions of local anesthetics including Formulation A following arthroscopic and other surgical procedures is an unapproved use, and there have been post-marketing reports of chondrolysis in patients receiving such infusions. (5.5)

Adverse Reactions

Adverse reactions reported with an incidence greater than or equal to 10% and greater than control following Formulation A administration in shoulder surgery were dizziness, dysgeusia, dysuria, headache, hypoesthesia, paresthesia, tinnitus, and vomiting (6.1).

Adverse reactions reported with an incidence greater than or equal to 10% and greater than control following Formulation A administration in soft tissue surgical procedures were anemia, bradycardia, constipation, C-reactive protein increased, diarrhea, dizziness, dysgeusia, headache, nausea, post procedural contusion (bruising), procedural pain, pruritus, pyrexia, somnolence, surgical site bleeding, visible bruising, and vomiting (6.1).

Use in Specific Populations

Moderate to Severe Hepatic Impairment: Consider reduced dosing and increased monitoring for bupivacaine toxicity.

1 Indications and Usage

Formulation A is indicated in adults for administration into the subacromial space under direct arthroscopic visualization to produce post-surgical analgesia for up to 72 hours following arthroscopic subacromial decompression.

Limitations of Use

Safety and effectiveness have not been established in other surgical procedures, including soft tissue surgical procedures, other orthopedic procedures, including for intra-articular administration, and boney procedures, or when used for neuraxial or peripheral nerve blockade.

Formulation A has not been studied for use in patients younger than 18 years of age.

2 Dosage and Administration 2.1 Important Dosage and Administration Information

-   -   Formulation A is intended for single-dose administration only.     -   Do not dilute or mix Formulation A with local anesthetics or         other drugs or diluents.     -   As there is a potential risk of severe, life-threatening adverse         reactions associated with the administration of bupivacaine,         Formulation A should be administered in a setting where trained         personnel and equipment are available to promptly treat patients         who show evidence of neurological or cardiac toxicity.     -   Different formulations of bupivacaine are not bioequivalent to         Formulation A even if the milligram dosage is the same. It is         not possible to convert dosing from any other formulations of         bupivacaine to Formulation A and vice versa. Do not substitute.     -   The toxic effects of local anesthetics are additive. Avoid         additional use of local anesthetics within 168 hours following         administration of Formulation A.     -   Avoid intravascular administration of Formulation A. Convulsions         and cardiac arrest have occurred following accidental         intravascular injection of bupivacaine and other         amide-containing products.     -   Formulation A is not indicated for the following routes of         administration.         -   Epidural         -   Intrathecal         -   Intravascular         -   Intra-articular use [see Nonclinical Toxicology (0)]         -   Regional nerve blocks         -   Pre-incisional or pre-procedural locoregional anesthetic             techniques that require deep and complete sensory block in             the area of administration.

2.2 Recommended Dose

The recommended dose of Formulation A is 660 mg (5 mL) for this study.

2.3 Preparation, Administration, and Dosing Instructions

-   -   Formulation A is ready to use and does not require dilution or         mixing.     -   Prior to administration, draw up Formulation A into a 5 mL         syringe using a large bore needle (16 gauge or larger). Once the         syringe has been filled, discard the large bore needle.     -   At the close of surgery, administer the entire 5 mL dose of         Formulation A into the subacromial space using an 18 gauge or         larger-bore needle. The needle may be inserted through an         existing arthroscopic port or through intact skin to reach the         subacromial space. Confirm correct placement of the needle tip         within the subacromial space by direct arthroscopic         visualization.     -   Do not administer Formulation A into the glenohumeral         intra-articular space.

2.4 Compatibility Considerations

Formulation A is compatible with:

-   -   Commonly implantable materials, such as polypropylene and         polyester     -   Silk, nylon, gut, polypropylene, polydioxanone, and polyglycolic         acid sutures

3 Dosage Forms and Strengths

Formulation A (bupivacaine solution) is a sterile, nonpyrogenic, clear, light yellow to amber solution in a clear, glass vial.

-   -   5 mL single-dose vial: 660 mg/5 mL (132 mg/mL)

4 Contraindications

Formulation A is contraindicated in:

-   -   Patients with a known hypersensitivity (e.g., anaphylactic         reactions and serious skin reactions) to any amide local         anesthetic, or other components of Formulation A.     -   Patients undergoing obstetrical paracervical block anesthesia.         The use of bupivacaine HCl with this technique has resulted in         fetal bradycardia and death.

5 Warnings and Precautions

5.1 Risk of Potential Adverse Embolic Effects Resulting from Inadvertent Intravascular Injection

Inadvertent intravascular injection could cause Formulation A droplets to be deposited in the pulmonary and other capillary beds. Administer Formulation A into the subacromial space at the end of arthroscopic shoulder surgery. Direct arthroscopic visualization must be used to confirm proper placement of the needle tip before injecting Formulation A.

5.2 Risk of Joint Cartilage Necrosis with Unapproved Intra-articular Use

The safety and effectiveness of Formulation A in surgical procedures other than subacromial decompression have not been established, and Formulation A is not approved for use via intra-articular injection. A study evaluating the effects of Formulation A and Formulation A vehicle in dogs following an intra-articular administration demonstrated joint cartilage necrosis [see Nonclinical Toxicology (0)].

5.3 Risk of Systemic Toxicity

Unintended intravascular injection of Formulation A may be associated with systemic toxicities, including CNS or cardiorespiratory depression and coma, progressing ultimately to respiratory arrest. Direct arthroscopic visualization must be used to confirm proper placement of the needle tip in the subacromial space before injecting Formulation A.

The safety and effectiveness of bupivacaine depend on proper dosage, correct technique, adequate precautions, and readiness for emergencies. Careful and constant monitoring of cardiovascular and respiratory (adequacy of ventilation) vital signs and the patient's state of consciousness should be performed after injection of bupivacaine.

Possible early warning signs of central nervous system (CNS) toxicity are restlessness, anxiety, incoherent speech, lightheadedness, numbness and tingling of the mouth and lips, metallic taste, tinnitus, dizziness, blurred vision, tremors, twitching, CNS depression, or drowsiness. Delay in proper management of systemic toxicity, underventilation from any cause, and/or altered sensitivity may lead to the development of acidosis, cardiac arrest, and, possibly, death.

Avoid additional use of local anesthetics within 168 hours following administration of Formulation A. Injection of repeated doses of bupivacaine may cause significant increases in plasma levels due to slow accumulation of the drug or its metabolites, or to slow metabolic degradation. Tolerance to elevated blood levels varies with the status of the patient. Consider increased monitoring for systemic toxicity in debilitated, elderly, or acutely ill patients.

5.4 Methemoglobinemia

Cases of methemoglobinemia have been reported in association with local anesthetic use. Although all patients are at risk for methemoglobinemia, patients with glucose-6-phosphate dehydrogenase deficiency, congenital or idiopathic methemoglobinemia, cardiac or pulmonary compromise, infants under 6 months of age, and concurrent exposure to oxidizing agents or their metabolites are more susceptible to developing clinical manifestations of the condition [see Drug Interactions (0)]. If local anesthetics must be used in these patients, close monitoring for symptoms and signs of methemoglobinemia is recommended.

Signs of methemoglobinemia may occur immediately or may be delayed some hours after exposure, and are characterized by a cyanotic skin discoloration and/or abnormal coloration of the blood. Methemoglobin levels may continue to rise; therefore, immediate treatment is required to avert more serious central nervous system and cardiovascular adverse effects, including seizures, coma, arrhythmias, and death. Discontinue any oxidizing agents. Depending on the severity of the signs and symptoms, patients may respond to supportive care, i.e., oxygen therapy, hydration. A more severe clinical presentation may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.

5.5 Chondrolysis with Intra-Articular Infusion of Local Anesthetics

Intra-articular infusions of local anesthetics including bupivacaine following arthroscopic and other surgical procedures is an unapproved use, and there have been post-marketing reports of chondrolysis in patients receiving such infusions. The majority of reported cases of chondrolysis have involved the shoulder joint; cases of gleno-humeral chondrolysis have been described in pediatric patients and adult patients following intra-articular infusions of local anesthetics with and without epinephrine for periods of 48 to 72 hours. There is insufficient information to determine whether shorter infusion periods are associated with chondrolysis. The time of onset of symptoms, such as joint pain, stiffness, and loss of motion can be variable, but may begin as early as the second month after surgery. Currently, there is no effective treatment for chondrolysis; patients who have experienced chondrolysis have required additional diagnostic and therapeutic procedures and some required arthroplasty or shoulder replacement.

5.6 Risk of Toxicity in Patients with Hepatic Impairment

Because amide local anesthetics such as bupivacaine are metabolized by the liver, consider reduced dosing and increased monitoring for bupivacaine systemic toxicity in patients with moderate to severe hepatic impairment who are treated with Formulation A [see Use in Specific Populations (0)].

5.7 Risk of Use in Patients with Impaired Cardiovascular Function

Care should be taken when considering the use of Formulation A in patients with impaired cardiovascular function (e.g., hypotension, heartblock) because they may be less able to compensate for functional changes associated with the prolongation of AV conduction produced by bupivacaine. Consider reduced dosing. Monitor patients closely for blood pressure, heart rate, and ECG changes.

6 Adverse Reactions

The following adverse reactions to bupivacaine hydrochloride are described elsewhere in other sections of the prescribing information:

-   -   Systemic Toxicity with Intravascular Injection [see Warnings and         Precautions (0.3)]     -   Methemoglobinemia [see Warnings and Precautions (5.4)]     -   Chondrolysis with Intra-Articular Infusion [see Warnings and         Precautions (0.5)]     -   Cardiovasular System Reactions [see Warnings and Precautions         (0.7)]

6.1 Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates observed in the clinical trials of another drug and may not reflect the rates observed in practice.

The safety of Formulation A, doses ranging from 2.5 mL to 5 mL, was evaluated in 10 randomized, double-blind, controlled trials. Overall, Formulation A 5 mL, the recommended dose, has been administered to a total of 735 patients in clinical trials using a variety of administration methods, including the recommended method of infiltration Instructions. Three trials were controlled with bupivacaine HCl, two trials were controlled with bupivacaine HCl and vehicle placebo, and five trials were controlled with vehicle placebo. An additional 47 patients were treated with saline placebo in one of the bupivacaine HCl-controlled trials. The evaluated surgical procedures included inguinal hernia repair, subacromial decompression of the shoulder, abdominal hysterectomy, open laparotomy, laparoscopic cholecystectomy, and laparoscopically-assisted colectomy.

Shoulder Surgical Procedures

There were three studies evaluating the safety of Formulation A administered during shoulder surgery. In Study 1, which corresponds to above Example 1, one of three treatments was administered into the subacromial space at the end of surgery: Formulation A, vehicle placebo, or bupivacaine HCl. Table 4.1 presents commonly-reported adverse reactions from Study 1.

TABLE 4.1 Commonly Reported Adverse Reactions from Study 1 (Incidence ≥2% and More Frequent than Bupivacaine HCl or Vehicle Placebo). Bupivacaine Vehicle Preferred Formulation A HCl Placebo Term, n (%) (N = 53) (n = 29) (N = 25) Headache 3 (5.7%) 1 (3.4%) 1 (4.0%) Electrocardiogram 2 (3.8%) 0 0 T wave inversion Hypoesthesia 2 (3.8%) 1 (3.4%) 1 (4.0%) Pruritus generalized 2 (3.8%) 0 0

In Study 2 and Study 3, which correspond to above Examples 2 and 3, respectively, patients were administered either Formulation A or vehicle placebo into the subacromial space at the end of surgery. Table 4.2 presents commonly-reported adverse reactions from Studies 2 and 3.

TABLE 4.2 Commonly Reported Adverse Reactions Pooled from Study 2 and Study 3 (Incidence ≥2% and More Frequent than Placebo). Preferred Formulation A Vehicle Placebo Term, n (%)* (N = 75) (N = 44) Dizziness 30 (40.3%) 17 (38.3%) Vomiting 22 (29.0%) 12 (26.6%) Headache 17 (23.3%) 7 (16.3%) Paresthesia 14 (18.4%) 7 (15.4%) Dysgeusia 13 (17.6%) 7 (14.9%) Hypoesthesia 13 (17.3%) 7 (15.8%) Tinnitus 10 (13.2%) 3 (6.7%) Dysuria 8 (10.1%) 4 (10.1%) Pyrexia 7 (9.3%) 2 (4.6%) Insomnia 5 (7.1%) 0 Dyspnea 3 (3.8%) 0 Muscle twitching 3 (3.8%) 0 Peripheral swelling 3 (3.9%) 0 Urinary retention 2 (2.7%) 1 (2.1%) Contusion 2 (2.5%) 0 Dysmenorrhea 2 (2.7%) 0 Incision site pruritus 2 (2.7%) 0 Nasal congestion 2 (2.5%) 0 Pruritus generalized 2 (2.5%) 0

Less common adverse reactions (incidence less than 2% and more frequent than either bupivacaine HCl or vehicle placebo) following Formulation A administration in shoulder surgical procedures were angina pectoris, blepharospasm, electrocardiogram T wave amplitude decreased, electrocardiogram T wave inversion, fatigue, osteoarthritis, procedural nausea, procedural pain, and pulmonary arterial hypertension.

Additional follow-up safety data consisting of shoulder MRI, physical examination of the shoulder, and assessments of wound healing were collected at 6 months in Study 1 and at 18 months in Study 2. There were no specific long-term follow-up evaluations for patients treated in Study 3; however, study investigators did not report any cases of chondrolysis in follow-up surveys. All surgical incisions were found to have healed as expected in all three studies. Table 4.3 presents the results of the MRI and physical examinations for Study 1. Table 4.4 presents the results of the MRI and physical examinations for Study 2.

TABLE 4.3 Long-term Follow-up Safety Data from Studies in Subacromial Decompression Study 1. Vehicle Bupivacaine Safety Evaluation Formulation A Placebo HCl Number enrolled 53 25 29 Shoulder MRI Number at 6-month follow-up 51 25 25 Improved ^([1]), n (%) 6 (11.8%) 2 (8.0%) 6 (24.0%) No change ^([1]), n (%) 31 (60.8%) 14 (56.0%) 9 (36.0%) Worsened ^([1]), n (%) 14 (27.4%) 9 (36%) 10 (40%) Constant-Murley score Number at 6-month follow-up 52 25 26 Pre-surgery, mean (SD) 44.7 (12.5%) 41.7 (11.7%) 42 (11.3%) Follow-up, mean (SD) 61.6 (15.2%) 63.2 (12.4%) 65.6 (6.8%) Decreased from 5 (9.6%) 2 (8.0%) 0 (0%) baseline, n (%) ^([1]) Compared with pre-surgical MRI

TABLE 4.4 18-Month Follow-up Safety Data from Subacromial Decompression Study 2. Safety Evaluation Formulation A Vehicle Placebo Number enrolled 40  20  Shoulder MRI Number at 18-month follow-up 27  14  Overall assessment Unexpected injuries or findings 0 0 compared with pre-surgical MRI, n (%) New-onset cartilage or bone lesions of concern 0 0 (not present at baseline and unrelated to surgery or natural disease progression), n (%) Glenohumeral joint and humeral head Presence of cartilage thinning - humeral head, n (%) Grade 0: normal/none 26 (96.3%) 14 (100%) Grade 1: mild 0 0 Grade 2: moderate 1 (3.7%) ^([1]) 0 Grade 3: severe 0 0 Rotator cuff and labrum Supraspinatus tendon tear, n (%) No tear 16 (59.3%) 5 (35.7%) Partial 7 (25.9%) 7 (50.0%) Full thickness 1 (3.7%) 0 Other findings 3 (11.1%) 2 (14.3%) Supraspinatus - other findings, n (%) Interstitial tear 0 0 Tendinosis 2 (7.4%) 1 (7.1%) Surgically repaired tendon 0 1 (7.1%) Interstitial tear/tendinosis 1 (3.7%) 0 (blank) 24 (88.9%) 12 (85.7%) Subacromial space - acromion Acromion boney spur, n (%) Yes 1 (3.7%) 0 No 26 (96.3%) 14 (100%) Acromion bone resection, n (%) Yes 18 (66.7%) 9 (64.3%) No 9 (33.3%) 5 (35.7%) Acromion signal abnormality (edema, fibrosis), n (%) Yes 2 (7.4%) ^([2]) 2 (14.3%) ^([2]) No 25 (92.6%) ^([2]) 12 (85.7%) ^([2]) Acromioclavicular joint Bone resection at acromioclavicular joint/postoperative changes, n (%) Yes 10 (37.0%) 4 (28.6%) No 16 (59.3%) 10 (71.4%) Not evaluable 1 (3.7%) 0 Joint effusion/synovitis, n (%) Grade 0: normal/none 9 (33.3%) 2 (14.3%) Grade 1: mild 9 (33.3%) ^([3]) 7 (50.0%) Grade 2: moderate 3 (11.1%) ^([3]) 3 (21.4%) ^([3]) Grade 3: severe 0 1 (7.1%) ^([3]) Not evaluable 6 (22.2%) 1 (7.1%) Bursa and Soft Tissue Subacromial bursa - bursitis/excess fluid, n (%) Grade 0: normal/none 18 (66.7%) 5 (35.7%) Grade 1: mild 6 (22.2%) 9 (64.3%) ^([4]) Grade 2: moderate 3 (11.1%) 0 Grade 3: severe 0 0 Physical Exam Number at 18-month follow-up 31  16  Clinical assessment, n (%) Normal 27 (87.1%) 13 (81.3%) Abnormal 4 (12.9%) 3 (18.8%) Pain intensity, 0-10 scale Mean (SE) 0.9 (0.4%) 1.2 (0.6%) Positive impingement sign, n (%) Yes 3 (9.7%) 3 (18.8%) No 28 (90.3%) 13 (81.3%) Full passive range of motion, n (%) Yes 27 (87.1%) 13 (81.3%) No 4 (12.9%) 3 (18.8%) ^([1]) The humeral head cartilage thinning was unchanged from baseline. ^([2]) Two Formulation A patients were positive for signal abnormalities at baseline and negative at 18 months. Two Formulation A patients were negative for signal abnormalities at baseline and positive at 18 months. One placebo patient was positive for signal abnormality at baseline and negative at 18 months. Two placebo patients were positive for signal abnormalities at both baseline and 18 months. ^([3]) Two Formulation A patients had joint effusion/synovitis that improved from moderate at baseline to mild at 18 months. One Formulation A patient had joint effusion/synovitis that improved from severe at baseline to mild at 18 months. Four patients (1 Formulation A, 3 placebo) had joint effusion/synovitis that worsened from mild at baseline to moderate at 18 months. One placebo patient had joint effusion/synovitis that worsened from mild at baseline to severe at 18 months. ^([4]) One placebo patient had bursitis/excess fluid that was severe at baseline and mild at 18 months.

Soft Tissue Surgical Procedures

There were two studies evaluating the safety of Formulation A in patients undergoing inguinal hernia repair (hernioplasty). Patients in these studies were administered either Formulation A (5 mL) or vehicle placebo; 2.5 mL administered into the floor of the inguinal canal and 2.5 mL administered into the subcutaneous space. Table 4.5 presents commonly-reported adverse reactions from these studies.

TABLE 4.5 Commonly Reported Adverse Reactions Pooled from Studies in Inguinal Hernia Repair (Incidence ≥2% and More Frequent than Placebo) Preferred Formulation A Vehicle Placebo Term, n (%)* (N = 69) (N = 53) Bradycardia 16 (22.9%) 7 (14.2%) Pruritus † 15 (21.6%) 9 (17.5%) Post procedural contusion 10 (14.0%) 5 (10.1%) (bruising) Vomiting 6 (9.4%) 4 (7.4%) Incision site swelling 4 (6.0%) 3 (5.7%) Dyspepsia 4 (5.7%) 2 (3.7%) Pyrexia 4 (6.0%) 2 (4.0%) Contusion 4 (5.7%) 0 Back pain 3 (4.1%) 2 (3.4%) Viral infection 3 (4.1%) 2 (4.0%) Incision site erythema 3 (4.1%) 0 Oropharyngeal pain 3 (4.6%) 0 Tachycardia 3 (4.6%) 0 Upper respiratory tract infection 2 (3.0%) 1 (2.0%) Dry throat 2 (3.2%) 0 Hyperhidrosis 2 (3.0%) 0 Hypertension 2 (2.8%) 0 Local swelling 2 (3.0%) 0 Testicular swelling 2 (3.2%) 0 *Percentages adjusted to account for the different sizes of the pooled studies. † Incision site pruritus, generalized pruritus, and genital pruritus were also reported, but none had incidence ≥2% and more frequent than placebo.

There were five studies evaluating the safety of Formulation A in laparoscopic, laparoscopically-assisted, or open abdominal surgeries.

In two studies in patients undergoing laparoscopic cholecystectomy, Formulation A or bupivacaine HCl was administered into the laparoscopic port incisions at the end of surgery. In one of these studies, a subset of patients received either Formulation A or saline placebo. In a study of patients undergoing laparoscopically-assisted colectomy, Formulation A or vehicle placebo was administered predominantly into the hand port incision at the end of surgery. In a study of patients undergoing laparotomy, Formulation A or bupivacaine HCl was administered into the full length of the surgical incision at the end of surgery. Table 4.6 presents commonly-reported adverse reactions from these four studies. Table 4.7 and Table 4.8 present, respectively, surgical-site adverse reactions and early-occurring central nervous system (CNS)-related adverse reactions from the laparoscopic cholecystectomy study that included a saline placebo control arm.

TABLE 4.6 Commonly Reported Adverse Reactions Pooled from Laparoscopic, Laparoscopically-Assisted, and Open Abdominal Surgery Studies (Incidence ≥2% and More Frequent than Bupivacaine HCl or Placebo). Bupivacaine Vehicle Preferred Formulation A HCl Placebo Term, n (%)* (N = 337) (N = 186) (N = 78) Post procedural 231 (71.2%) 119 (61.8%) 41 (52.6%) contusion (bruising) Nausea 189 (55.8%) 111 (59.6%) 40 (51.3%) Constipation 112 (35.2%) 80 (41.8%) 8 (10.3%) Somnolence 92 (30.4%) 80 (41.0%) 3 (3.8%) Headache 86 (27.2%) 63 (32.3%) 12 (15.4%) Dizziness 75 (23.5%) 58 (30.1%) 6 (7.7%) Vomiting 66 (19.4%) 39 (21.0%) 6 (7.7%) Dysgeusia 50 (16.2%) 33 (16.9%) 2 (2.6%) Pruritus † 45 (14.3%) 36 (18.7%) 5 (6.4%) Procedural pain 35 (11.4%) 35 (17.8%) 0 Diarrhea 34 (9.8%) 10 (5.5%) 10 (12.8%) Incision site 30 (8.7%) 6 (3.0%) 3 (3.8%) hemorrhage Pyrexia 29 (8.2%) 10 (5.7%) 11 (14.1%) Abdominal distension 29 (8.2%) 8 (4.8%) 12 (15.4%) Incision site erythema 29 (8.1%) 5 (2.7%) 10 (12.8%) Post procedural 26 (7.5%) 8 (4.4%) 7 (9.0%) discharge Paresthesia 23 (7.5%) 25 (13.1%) 2 (2.6%) Hypokalemia 22 (5.9%) 2 (1.4%) 10 (12.8%) Incision site hematoma 18 (5.2%) 3 (1.7%) 4 (5.1%) Anemia 17 (4.5%) 1 (0.7%) 7 (9.0%) Flatulence 16 (4.6%) 7 (4.0%) 8 (10.3%) Hypertension 16 (4.6%) 7 (3.6%) 1 (1.3%) Incision site 16 (4.5%) 4 (2.5%) 2 (2.6%) infection Musculoskeletal pain 15 (4.2%) 8 (4.9%) 0 Abdominal pain 15 (4.4%) 1 (0.5%) 1 (1.3%) Insomnia 14 (3.9%) 5 (2.9%) 7 (9.0%) Dyspepsia 13 (3.8%) 3 (1.9%) 4 (5.1%) Wound dehiscence 13 (3.6%) 3 (1.5%) 5 (6.4%) Cough 12 (3.6%) 3 (1.8%) 1 (1.3%) Oropharyngeal pain 12 (3.5%) 2 (1.0%) 0 Urinary retention 10 (2.8%) 2 (1.2%) 4 (5.1%) Chest pain 10 (2.9%) 1 (0.5%) 1 (1.3%) Ileus 10 (2.7%) 1 (0.7%) 3 (3.8%) Body temperature 9 (2.4%) 0 2 (2.6%) increased Abdominal pain upper 8 (2.5%) 2 (1.0%) 0 Rash 7 (2.1%) 7 (3.8%) 1 (1.3%) Pain in extremity 7 (2.1%) 5 (2.8%) 1 (1.3%) Dry mouth 7 (2.2%) 2 (1.0%) 1 (1.3%) Nasopharyngitis 7 (2.1%) 0 0 *Percentages adjusted to account for the different sizes of the pooled studies. † Incision site pruritus, generalized pruritus, eye pruritus, anal pruritus, and infusion site pruritus were also reported, but none had incidence ≥2% and more frequent than placebo.

TABLE 4.7 Incidence of Surgical Site Adverse Reactions from Laparoscopic Cholecystectomy Study with Saline Placebo and Bupivacaine HCl Controls. Saline Placebo Control Bupivacaine HCl Control Saline Bupivacaine Prespecified Formulation A Placebo Formulation A HCl Term*, n (%) (N = 45) (N = 47) (N = 148) (N = 148) Visible bruising 41 (91.1%) 33 (70.2%) 142 (95.9%) 105 (70.9%) Surgical site bleeding 22 (48.9%) 20 (42.6%) 19 (12.8%) 24 (16.2%) Drainage from surgical 2 (4.4%) 3 (6.4%) 11 (7.4%) 6 (4.1%) incision(s) Wound hematoma 0 0 6 (4.1%) 2 (1.4%) Wound dehiscence 0 0 2 (1.4%) 3 (2.0%) Surgical site infection 0 0 2 (1.4%) 1 (0.7%) *Terms were prespecified for examination by a blinded assessor on postoperative days 0, 4, 7, 14, 28, and 59.

TABLE 4.8 CNS-related Adverse Reactions Solicited from Subjects at 6 Hours Post-surgery in Laparoscopic Cholecystectomy Study with Saline Placebo and Bupivacaine HCl Controls. Dictionary- Derived Term Saline Placebo Control Bupivacaine HCl Control (Symptom)* Saline Bupivacaine Entire Formulation A Placebo Formulation A HCl study, n (%) (N = 45) (N = 47) (N = 148) (N = 148) Somnolence (Drowsiness) 18 (40.0%) 16 (34.0%) 60 (40.5%) 48 (32.4%) Nausea (Nausea) 9 (20.0%) 13 (27.7%) 48 (32.4%) 57 (38.5%) Dizziness (Dizziness) 3 (6.7%) 3 (6.4%) 28 (18.9%) 31 (20.9%) Headache (Headache) 5 (11.1%) 4 (8.5%) 23 (15.5%) 18 (12.2%) Vomiting (Vomiting) 2 (4.4%) 3 (6.4%) 10 (6.8%) 15 (10.1%) Constipation (Constipation) 0 (0.0%) 4 (8.5%) 9 (6.1%) 10 (6.8%) Pruritus (Itching) 1 (2.2%) 1 (2.1%) 6 (4.1%) 5 (3.4%) Subset of study, n (%) N = 23 N = 22 Dysgeusia (Metallic 3 (13.0%) 2 (9.1%) 26 (17.6%) 22 (14.9%) taste in mouth) Paresthesia (Tingling) 0 0 2 (1.4%) 6 (4.1%) Hypoesthesia (Numbness) 0 0 1 (0.7%) 1 (0.7%) *Patients responded to a 10-symptom checklist (7 symptoms for part of the saline placebo-controlled portion of the study).

In a study of patients undergoing total abdominal hysterectomy, Formulation A, vehicle placebo, or bupivacaine HCl was administered into the surgical incision at the end of surgery. Table 4.9 presents commonly-reported adverse reactions from this study.

TABLE 4.9 Commonly Reported Adverse Reactions from Total Abdominal Hysterectomy Study (Incidence ≥2% and More Frequent than Bupivacaine HCl). Bupivacaine Vehicle Formulation A HCl Placebo Preferred Term (N = 60) (N = 27) (N = 27) Post procedural contusion 36 (60.0%) 0 9 (33.3%) (bruising) Anemia 10 (16.7%) 3 (11.1%) 4 (14.8%) Dizziness 9 (15.0%) 4 (14.8%) 3 (11.1%) Vomiting 9 (15.0%) 4 (14.8%) 8 (29.6%) C-reactive protein increased 7 (11.7%) 1 (3.7%) 0 Pyrexia 7 (11.7%) 7 (25.9%) 3 (11.1%) Somnolence 5 (8.3%) 2 (7.4%) 0 Blood potassium decreased 4 (6.7%) 0 1 (3.7%) Hypertension 4 (6.7%) 2 (7.4%) 1 (3.7%) Incision site hematoma 3 (5.0%) 0 0 Electrocardiogram change 2 (3.3%) 0 0 Procedural hemorrhage 2 (3.3%) 0 0 Vaginal hematoma 2 (3.3%) 0 0

Less common adverse reactions (incidence less than 2% and more frequent than either bupivacaine HCl or placebo) following Formulation A administration in soft tissue surgical procedures were: application site irritation, atrial fibrillation, drug eruption, electrocardiogram QT prolonged, eructation, erythema, excessive granulation tissue, fatigue, genital pain, heart rate increased, hiccups, hypoesthesia, hypogeusia, incision site cellulitis, incision site erosion, incision site hypoesthesia, incision site inflammation, incision site edema, incision site pain, incision site rash, mean arterial pressure increased, micturition urgency, night sweats, overdose, palpitations, procedural hypertension, pruritus generalised, rash generalized, seroma, sinus tachycardia, skin discolouration, tinnitus, and wound haemorrhage.

7 Drug Interactions

Do not dilute or mix Formulation A with local anesthetics or other drugs or diluents. Avoid additional use of local anesthetics within 168 hours following administration of FORMULATION A.

7.1 Drugs Associated with Methemoglobinemia

Patients who are administered Formulation A are at increased risk of developing methemoglobinemia when concurrently exposed to following drugs, which could include other local anesthetics [see Warnings and Precautions (0)].

Examples of Drugs Associated with Methemoglobinemia:

Class Examples Nitrates/Nitrites nitric oxide, nitroglycerin, nitroprusside, nitrous oxide Local anesthetics articaine, benzocaine, bupivacaine, lidocaine, mepivacaine, prilocaine, procaine, ropivacaine, tetracaine Antineoplastic cyclophosphamide, flutamide, agents hydroxyurea, ifosfamide, rasburicase Antibiotics dapsone, nitrofurantoin, para-aminosalicylic acid, sulfonamides Antimalarials chloroquine, primaquine Anticonvulsants phenobarbital, phenytoin, sodium valproate Other drugs acetaminophen, metoclopramide, quinine, sulfasalazine

8 Use in Specific Populations 8.1 Pregnancy Risk Summary

There are no studies conducted with Formulation A in pregnant women. In animal studies, embryo-fetal lethality was noted when bupivacaine was administered subcutaneously to pregnant rabbits during organogenesis at 0.6 times the maximum recommended human dose of Formulation A at 660 mg bupivacaine. Decreased pup survival was observed in a rat pre- and post-natal development study (dosing from implantation through weaning) at 0.6 times the maximum recommended human dose of Formulation A at 660 mg bupivacaine. Based on animal data, advise pregnant women of the potential risks to a fetus. [see Data]

The background risk of major birth defects and miscarriage for the indicated population is unknown. However, the background risk in the U.S. general population of major birth defects is 2%-4% and of miscarriage is 15%-20% of clinically recognized pregnancies.

Clinical Considerations Labor or Delivery

Bupivacaine is contraindicated for obstetrical paracervical block anesthesia. While Formulation A has not been studied with this technique, the use of bupivacaine for obstetrical paracervical block anesthesia has resulted in fetal bradycardia and death. Bupivacaine can rapidly cross the placenta, and when used for epidural, caudal, or pudendal block anesthesia, can cause varying degrees of maternal, fetal, and neonatal toxicity (Formulation A is not indicated for these uses). The incidence and degree of toxicity depend upon the procedure performed, the type, and amount of drug used, and the technique of drug administration. Adverse reactions in the parturient, fetus, and neonate involve alterations of the central nervous system, peripheral vascular tone, and cardiac function.

Data Animal Data

Bupivacaine hydrochloride produced developmental toxicity when administered subcutaneously to pregnant rats and rabbits at clinically relevant doses.

Bupivacaine hydrochloride was administered subcutaneously to rats at doses of 4.4, 13.3, & 40 mg/kg and to rabbits at doses of 1.3, 5.8, & 22.2 mg/kg during the period of organogenesis (implantation to closure of the hard palate). The high doses are approximately 0.6 times the daily maximum recommended human dose (MRHD) of 660 mg/day on a mg/m² body surface area (BSA) basis. No embryo-fetal effects were observed in rats at the high dose which caused increased maternal lethality. An increase in embryo-fetal deaths was observed in rabbits at the high dose in the absence of maternal toxicity with the fetal No Observed Adverse Effect Level representing approximately 0.2 times the MRHD on a BSA basis.

In a rat pre- and post-natal developmental study (dosing from implantation through weaning) conducted at subcutaneous doses of 4.4, 13.3, & 40 mg/kg, decreased pup survival was observed at the high dose. The high dose is approximately 0.6 times the daily MRHD of 660 mg/day on a BSA basis.

8.2 Lactation Risk Summary

Formulation A has not been studied in nursing mothers. Bupivacaine can persist in plasma for up to 168 hours [see Clinical Pharmacology (0)] and benzyl alcohol, a FORMULATION A excipient, for up to 12 hours after Formulation A administration. Both bupivacaine and benzyl alcohol have been reported to be excreted in human milk. The developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for Formulation A and any potential adverse effects on the breastfed infant from Formulation A or from the underlying maternal condition.

8.3 Pediatric Use

Safety and effectiveness of Formulation A in pediatric patients below the age of 18 have not been established.

8.4 Geriatric Use

Of the total number of patients enrolled in the Formulation A clinical studies (N=1463), 167 patients were older than 65 years and 32 patients were older than 75 years.

In bupivacaine clinical studies, differences in various pharmacokinetic parameters have been observed between elderly and younger adult patients. Bupivacaine is known to be substantially excreted by the kidney, and the risk of adverse reactions to bupivacaine may be greater in patients with impaired renal function. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function. Elderly patients may require lower doses of Formulation A. Consider increased monitoring for local anesthetic systemic toxicity when administering Formulation A to elderly patients.

8.5 Hepatic Impairment

Because amide-type local anesthetics, such as bupivacaine, are metabolized by the liver, these drugs should be used with caution in patients with hepatic impairment. Patients with severe hepatic impairment, because of their inability to metabolize local anesthetics normally, are at a greater risk of developing toxic plasma concentrations, and potentially local anesthetic systemic toxicity. Care should be taken when considering the use of Formulation A in patients with impaired hepatic function and consider reduced dosing. Consider increased monitoring for local anesthetic systemic toxicity in patients with moderate to severe hepatic impairment when administering Formulation A.

8.6 Renal Impairment

Bupivacaine is known to be substantially excreted by the kidney, and the risk of adverse reactions to this drug may be greater in patients with impaired renal function. Care should be taken when considering the use of Formulation A in patients with impaired renal function. Consider increased monitoring for local anesthetic systemic toxicity when administering Formulation A to patients with impaired renal function.

10 Overdosage

Acute emergencies from local anesthetics are generally related to high plasma concentrations encountered during therapeutic use of local anesthetics or to unintended intravascular injection of local anesthetic solution [see Warnings and Precautions (0)].

In the clinical study program, a maximum plasma concentration (C_(max)) of 2850 ng/mL was reported. No apparent bupivacaine-related adverse reactions or clinical sequelae were observed in patients with high bupivacaine plasma concentrations.

11 Description

Formulation A (bupivacaine solution) is a sterile nonpyrogenic, clear, light yellow to amber solution for infiltration. Over time, the solution color will intensify within the range, from light yellow to amber. The range of color is not associated with a change in potency of the drug product. Formulation A contains bupivacaine (132 mg/mL), benzyl alcohol, and sucrose acetate isobutyrate.

Bupivacaine, an amide-type local anesthetic, is 1-butyl-N-(2,6-dimethylphenyl)-2-piperidinecarboxamide. It is a white crystalline powder with a molecular weight of 288.43 g/mol. The structure of bupivacaine is shown below:

Bupivacaine is present in Formulation A at a concentration of 132 mg/mL.

12 Clinical Pharmacology 12.1 Mechanism of Action

Bupivacaine blocks the generation and the conduction of nerve impulses, presumably by increasing the threshold for electrical excitation in the nerve, by slowing the propagation of the nerve impulse, and by reducing the rate of rise of the action potential. In general, the progression of anesthesia is related to the diameter, myelination and conduction velocity of affected nerve fibers. Clinically, the order of loss of nerve function is as follows: (1) pain, (2) temperature, (3) touch, (4) proprioception, and (5) skeletal muscle tone.

12.2 Pharmacodynamics

Systemic absorption of bupivacaine produces effects on the cardiovascular and central nervous systems. At blood concentrations achieved with therapeutic doses, changes in cardiac conduction, excitability, refractoriness, contractility, and peripheral vascular resistance are minimal. However, toxic blood concentrations depress cardiac conduction and excitability, which may lead to atrioventricular block, ventricular arrhythmias and to cardiac arrest, sometimes resulting in fatalities. In addition, myocardial contractility is depressed and peripheral vasodilation occurs, leading to decreased cardiac output and arterial blood pressure. These cardiovascular changes are more likely to occur after unintended intravascular injection of liquid formulations of bupivacaine.

Following systemic absorption, local anesthetics can produce central nervous system stimulation, depression or both. Apparent central stimulation is usually manifested as restlessness, tremors and shivering, progressing to convulsions, followed by depression and coma, progressing ultimately to respiratory arrest. However, the local anesthetics have a primary depressant effect on the medulla and on higher centers. The depressed stage may occur without a prior excited stage.

12.3 Pharmacokinetics

Infiltration of Formulation A into the surgical wound results in plasma levels of bupivacaine that can persist for 168 hours. Systemic plasma levels of bupivacaine following administration of Formulation A are not correlated with local efficacy.

Absorption

The rate of systemic absorption of bupivacaine is dependent upon the total dose of drug administered, the route of administration, and the vascularity of the administration site. Pharmacokinetic parameters of bupivacaine are shown in Table 4.10 after single-dose infiltration of Formulation A in arthroscopic subacromial decompression surgical procedure.

TABLE 4.10 Summary of Pharmacokinetic Parameters for Bupivacaine after Administration of a Single Dose of Formulation A 5 mL (660 mg) C_(max) AUC_(0-t) ^(#) T_(max) T_(1/2) Surgical Procedure (ng/mL) (h · ng/mL) (h){circumflex over ( )} (h) Arthroscopic N 36 36 36 36 subacromial Mean 593 19395 5.9{circumflex over ( )} 16.4 decompression SD 299 12056 1.0-24.0{circumflex over ( )} 5.1 Study 1* Arthroscopic N 18 18 18 18 subacromial Mean 1006 47015 8.0{circumflex over ( )} 26.1 decompression SD 454 20040 2.1-26.9{circumflex over ( )} 8.2 Study 3 ^(#)t = last sampling time {circumflex over ( )}Range (min, max) *Drug leakage from the surgical site was suspected.

Distribution

Depending upon the route of administration, bupivacaine is distributed to some extent to all body tissues, with high concentrations found in highly perfused organs such as the liver, lungs, heart, and brain.

Bupivacaine appears to cross the placenta by passive diffusion. The rate and degree of diffusion is governed by (1) the degree of plasma protein binding, (2) the degree of ionization, and (3) the degree of lipid solubility. Fetal/maternal ratios of local anesthetics appear to be inversely related to the degree of plasma protein binding, because only the free, unbound drug is available for placental transfer. Bupivacaine with a high protein binding capacity (95%) has a low fetal/maternal ratio (0.2 to 0.4). The extent of placental transfer is also determined by the degree of ionization and lipid solubility of the drug. Lipid soluble, non-ionized drugs such as bupivacaine readily enter the fetal blood from the maternal circulation.

Elimination

The mean half-life of bupivacaine after Formulation A administration in adults who underwent arthroscopic subacromial decompression range from 16.4 to 26.1 hours.

Metabolism

Amide-type local anesthetics such as bupivacaine are metabolized primarily in the liver via conjugation with glucuronic acid. Pipecoloxylidine is the major metabolite of bupivacaine. The elimination of drug from tissue distribution depends largely upon the availability of binding sites in the circulation to carry it to the liver where it is metabolized.

Excretion

The kidney is the main excretory organ for most local anesthetics and their metabolites. Urinary excretion is affected by urinary perfusion and factors affecting urinary pH. Only 6% of bupivacaine is excreted unchanged in the urine.

Specific Populations Hepatic Impairment

Pharmacokinetics of Formulation A have not been evaluated in patients with hepatic impairment [see Warnings and Precautions (0) and Use in Specific Populations (0)].

Renal Impairment

Pharmacokinetics of Formulation A have not been evaluated in patients with renal impairment [see Use in Specific Populations (0)].

Geriatric Patients

Pharmacokinetics of Formulation A have not been evaluated in geriatric patients.

Elderly patients have exhibited higher peak plasma concentrations than younger patients following administration of bupivacaine HCl. The total plasma clearance was decreased in these patients [see Use in Specific Populations (0)].

13 Nonclinical Toxicology 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility Carcinogenesis

Long-term studies in animals to evaluate the carcinogenic potential of bupivacaine hydrochloride have not been conducted.

Mutagenesis

Bupivacaine was negative in the in vitro bacterial reverse mutation assay (Ames assay), the in vitro chromosomal aberration assay (human peripheral blood lymphocytes, and the in vivo rat micronucleus assay.

Impairment of Fertility

The effect of bupivacaine on fertility has not been determined.

13.2 Animal Toxicology and/or Pharmacology

Necrosis of the joint cartilage was observed following intra-articular injection of a single dose of Formulation A or Formulation A vehicle in the dog model.

14 Clinical Studies

The effectiveness of Formulation A was evaluated in ten adequate and well-controlled studies in patients undergoing open and laparoscopic abdominal procedures, abdominal hysterectomy, inguinal hernia repair, and open and arthroscopic shoulder procedures. Adequate evidence of effectiveness was demonstrated in one of three studies conducted in patients undergoing shoulder surgery (described in detail below) and was not demonstrated in any soft tissue procedure evaluated.

Study 1

Study 1 was a randomized, multicenter, assessor blinded, placebo-controlled (vehicle) clinical trial in 107 patients undergoing arthroscopic subacromial decompression surgery with an intact rotator cuff. Associated procedures included inspection of the glenohumeral joint, distal clavicle excision, bursectomy, synovectomy, removal of loose body, resection of coracoacromial ligament and subacromial spurs, rotator cuff debridement, and minor debridement of articular cartilage. There were no open surgical procedures performed during this study. The mean age was 50 years (range 21 to 70 years), 60% of treated patients were female, 96% were White, 2% were Hispanic, 1% were Asian, and 1% were Other.

Patients were randomized 2:1:1 to receive Formulation A, vehicle placebo, or bupivacaine HCl 50 mg, and all patients received general anesthesia. No analgesic pre-medication or local anesthetics were administered. Formulation A and vehicle placebo were administered under direct arthroscopic visualization as single injections into the subacromial space through one of the arthroscopic portals at the end of the surgery. Bupivacaine HCl 50 mg was administered subacromially as a single dose. Post-operatively, patients received acetaminophen 500 mg or 1000 mg every six hours, depending on body weight, through 72 hours, and were allowed morphine rescue medication as needed, either 2 mg IV or 10 mg orally. Pain intensity was rated by the patients using a 0 to 10 numerical rating scale (NRS) at multiple time points up to 72 hours.

The primary outcome measures were the normalized area under the curve (nAUC) of mean pain intensity on movement scores collected at specified intervals over the first 72 hours after surgery and total opioid rescue analgesia (IV morphine-equivalent dose) through 72 hours. In this clinical study, Formulation A 5 mL demonstrated a significant reduction in mean pain intensity compared with placebo of 1.3 points on a 0-10 NRS scale over 72 hours (FIG. 10).

The median total use of opioid rescue analgesia (IV morphine equivalent dose) from 0 to 72 hours for the Formulation A treatment group (4 mg) was statistically lower than for the placebo treatment group (12 mg). The median use of opioid rescue analgesia in the bupivacaine treatment group was 8 mg.

Study 2

Study 2 was a randomized, double-blind, placebo-controlled (vehicle) clinical trial in 60 patients undergoing arthroscopic subacromial decompression, inspection of glenohumeral joint, synovectomy, removal of loose body, minor debridement of articular cartilage, minor debridement or minor repair of rotator cuff, open distal clavicle excision, bursectomy, and resection of coracoacromial ligament and subacromial spurs. The mean age was 48 years (range 27 to 68 years), 55% of treated patients were female, 95% were White, 2% were Asian, and 2% were Other.

Patients were randomized 2:1 to receive Formulation A or vehicle placebo, and all patients received general anesthesia. Post-operatively, patients were allowed morphine rescue medication as needed, either 3 mg IV or 10 mg to 15 mg orally, or acetaminophen. Pain intensity was rated by the patients using a 0 to 10 numerical rating scale (NRS) at multiple time points up to 72 hours.

The primary outcome measures were mean pain intensity on movement AUC through 72 hours and total opioid rescue analgesia (IV morphine-equivalent dose) through 72 hours. There was no statistically significant difference in either primary endpoint between the Formulation A and vehicle placebo treatment groups (FIG. 11).

Study 3

Study 3 was a randomized, double-blind, placebo-controlled (vehicle) and open-label PK clinical trial in 92 patients undergoing a variety of shoulder surgical procedures, including rotator cuff repair, subacromial decompression, glenoid labrum repair or debridement, and biceps tendon repair. The majority of patients underwent arthroscopic procedures; however, six patients underwent a combination of arthroscopic and open procedures. The mean age was 54 years (range 20 to 82 years), 59% of treated patients were male, 87% were White, 8% were African American, 3% were Other, and 2% were Asian.

An equal number of patients were randomized to two cohorts. The routes of Formulation A or vehicle placebo administration in Cohort 1 were subacromial or subcutaneous injection or a combination. In Cohort 2, Formulation A or vehicle placebo was administered via injection under direct arthroscopic visualization into the subacromial space. Surgical procedures were completed either under local or general anesthesia. Post-operatively, patients were allowed morphine IV, oxycodone orally, or acetaminophen orally as needed.

The primary outcome measures were mean pain intensity on movement and at rest through 120 hours and pain control through day seven. There was no statistically significant difference in either primary endpoint between Formulation A and vehicle placebo treatment groups (FIG. 12).

16 how Supplied/Storage and Handling

Formulation A (bupivacaine solution) is available in single-dose vials. It is a sterile nonpyrogenic, clear, light yellow to amber solution in glass vials.

5 mL single-dose vial, 660 mg/5 mL (132 mg/mL) packaged in a 10-unit carton

Storage

Formulation A vial should be stored at a controlled room temperature of 20° C. to 25° C. (68° F. to 77° F.), excursions permitted to 15° C. to 30° C. (59° F. to 86° F.) [see USP Controlled Room Temperature]. Vial should be protected from light and retained in carton until time of use.

Handling

Do not administer any solution which contains particulate matter.

Do not autoclave.

Do not dilute.

Discard any unused portion in an appropriate manner.

17 Patient Counseling Information

Patients should be informed in advance that bupivacaine-containing products can cause temporary loss of sensation or motor activity in the area of infiltration. The physician should discuss other information including adverse reactions in the Formulation A package insert with their patients.

Example 5

A gamma irradiation dose escalation study was conducted in which the level of the genotoxic degradant, 2,6-dimethylaniline, increased as a function of irradiation dose. A formulation was exposed to 0, 10, 20, or 35 kGy. The formulation consisted of 12 wt % bupivacaine, 66 wt % SAIB, and 22 wt % benzyl alcohol (“Formulation A”).

As discussed below, even low level irradiation (10 kGy) of the product generated significant amounts of 2,6-dimethylaniline.

Abstract

Formulation A after terminal sterilization by gamma irradiation at nominal exposures of 10, 20, and 35 kGy showed color changes (light yellow to yellow), an increase of the major degradant bupivacaine N-oxide from 0.27% to 0.43-0.53%, an increase of the degradant 2,6-dimethylaniline (2,6-DMA) from a non-detected level to 0.02-0.08% (or 75-302 parts per million, or ppm), and an increase of unknown drug related degradant peaks from 2 peaks to 4-12 peaks, while the potency decreased from 98.9% to 96.1-97.1%, as determined by reverse phase HPLC.

Stability of Formulation A at 0, 10, 20, and 35 kGy was monitored at 25° C./60% RH and 40° C./75% RH for up to 20 months. The formulation color continued to darken from yellow to brown at 25° C./60% RH and became a darker brown at 40° C./75% RH. After 20 months at 25° C./60% RH, data from HPLC for the different irradiated groups showed an insignificant decrease in potency from the corresponding initial T=0 timepoint, a slight increase (0.09-0.19%) in bupivacaine N-oxide, no significant increase in 2,6-DMA, and a small increase (0.09-0.17%) in the total amount of degradants. The control and 10 kGy exposed formulations showed a slight increase in the numbers of unknown detected peaks compared to that of the 20 and 35 kGy exposed formulations.

Objective

The objective of this study was to evaluate the effect of different exposure levels of gamma irradiation on the stability of Formulation A. The target nominal dose levels of gamma irradiation were 10, 20, and 35 kGy, with a control that was not irradiated (0 kGy).

Background and Introduction

The composition of Formulation A was bupivacaine base/sucrose acetate isobutyrate (SAIB)/benzyl alcohol (BA) at a % w/w ratio of 12/66/22, respectively. An unfiltered lot was filled into 200 vials, capped with non-siliconized Teflon stoppers, and sealed with aluminum crimp seals. The 200 vials were further divided into four groups of 50 vials each. One group was not irradiated, and the remaining three groups were terminally sterilized by gamma irradiation at 10, 20, and 35 kGy, respectively. All four groups were placed on stability at 25° C./60% RH and 40° C./75% RH in an upright position. A placebo lot exposed to similar gamma irradiation conditions as the active lot was used to identify those impurities related to the excipients, which were therefore excluded from the drug related degradant calculations.

The effect of gamma irradiation dose escalation was evaluated by a visual method and EP (European Pharmacopoeia) 2.2.2 (degree of coloration), and by HPLC. Tests were conducted on stability samples at 6 and 20 months at 25° C./60% RH, and at 3 and 20 months at 40° C./75% RH. Compositions of bupivacaine/sucrose acetate isobutyrate/benzyl alcohol exhibited a light yellow coloration prior to gamma irradiation. Visual inspection and characterization by EP 2.2.2 was conducted to assess the extent to which the compositions formed darker yellow to brown coloration.

2,6-DMA is a potential genotoxic degradant resulting from degradation of the drug substance or drug product by hydrolysis of the amide bond in bupivacaine. Since 2,6-DMA exhibits a different response factor (RF) from that of bupivacaine, its relative response factor (RRF) from system suitability (SYS) solution injections was applied to convert the % 2,6-DMA value by peak area normalization to 2,6-DMA as expressed as ppm relative to bupivacaine base.

Scope

Physical and chemical stability data were generated for Formulation A after exposure to gamma irradiation at levels of 0 kGy (control), 10 kGy (9.1_(min)-10.1_(max)), 20 kGy (19.2_(min)-22.0_(max)), and 35 kGy (31.7_(min)-36.0_(max)). The stability of non-irradiated and gamma irradiated Formulation A samples was determined for up to 20 months at 25° C./60% RH and 40° C./75% RH. The product was characterized for visual appearance, visual color, potency and degradation products. Placebo vials were stored under the same conditions as that for the actives, and were tested to identify potential excipient related degradants that may form in the active Formulation A. These placebo excipient degradants were excluded from the degradation product calculations for Formulation A.

Equipment, Materials and Analytical Methods

The equipment and material used in this study are listed in the below Table 5.1.

TABLE 5.1 Items Vendor/Model Bupivacaine Base Orgamol Benzyl Alcohol JT Baker Sucrose Acetate Isobutyrate DURECT Corporation (SAIB) Container West Pharmaceutical, 10 mL Type 1 borosilicate glass vial Bupivacaine Base Reference Orgamol Standard Bupivacaine N-Oxide Standard Chemic Lab Inc Benzaldehyde Aldrich 2,6-Dimethylaniline (DMA) Spectrum Benzyl Acetate Aldrich Benzyl Isobutyrate Aldrich EP color standards Fluka Stopper West Pharmaceutical, 20 mm, 4432/50 gray, non- silconized Teflon faced rubber stopper Seal West Pharmaceutical, 20 mm flip off aluminum crimp seal HPLC System Agilent 1100 series

Results and Discussion Appearance (Clarity)

There was no noticeable change in solution clarity for non-irradiated and irradiated Formulation A at T=0 and on storage at both 25° C./60% RH and 40° C./75% RH for up to 20 months.

Degree of Coloration

Formulation A was exposed to different target irradiation levels (0, 10, 20, and 35 kGy). Table 5.2 summarizes the results for the formulation color changes due to the gamma-irradiation process, and after storage at 25° C./60% RH and 40° C./75% RH for up to 20 months.

TABLE 5.2 Degree of Coloration Visual Test for Formulation A Exposed to Nominal Gamma Irradiation Levels of 0, 10, 20 and 35 kGy Stored at 25° C./60% RH and 40° C./75% RH up to 20 Months Using EP 2.2.2 Lot 1.1 Dose Level of Gamma Irradiation/EP reference Standard BY^(1,2) Condition Month³ 0 kGy 10 kGy 20 kGy 35 kGy 25° C./60% RH⁴ 1 BY3 BY1 >BY1 >BY1 Lightly yellow Yellow++ Darker yellow Darker Yellow 25° C./60% RH⁴ 3 >BY3 >BY1 >BY1 >BY1 Light yellow+ Darker yellow Darker yellow Darker yellow 25° C./60% RH⁴ 6 >BY2 >BY1 >BY1 >BY1 Yellow+ Darker yellow Darker yellow Darker yellow 25° C./60% RH 20⁵ >BY1 <BO <BO BO Darker yellow Lightly brown Lightly brown Lightly brown yellow yellow yellow 40° C./75% RH 1 BY2 >BY1 <BO BO Yellow Darker yellow Lightly brown Brown yellow yellow 40° C./75% RH 3 >BY1 BO BO BO Darker yellow Brown yellow Brown yellow Brown yellow 40° C./75% RH 20⁵ <BX BX BX BX Lightly dark Dark brown Dark brown Dark brown brown ¹EP standard BY series color ranking: BY1 (yellow) > BY2 (yellow) > BY3 (light yellow) ²Non-compendias standards from Fluka: BO = brown yellow, BX = dark brown. BX is a darker color than BO. ³1-month data results served as initial data. ⁴Color ranking (BY1) for irradiated Formulation A: BY1_(35 kGy) > BY1_(20 kGy) > BY1_(10 kGy) ⁵Performed after vials were pulled and stored at ambient temperature for approximately 2 months.

Effect of Gamma-Irradiation

The results indicate that gamma irradiation increased the color in the formulations from light yellow (non-irradiated formulation) to yellow (exposed to irradiation), with each higher level of irradiation causing a darker yellow color.

Effect of Storage at 25° C./60% RH and 40° C./75% RH

For all 4 groups of formulation, the degree of coloration increased with time at both storage conditions, and the accelerated condition (40° C./75% RH) darkened the formulation color faster than that at 25° C./60% RH.

After 20 months Storage:

-   -   Non-irradiated formulation changed color from light yellow (BY3)         to darker yellow (>BY1) at 25° C./60% RH, and to dark brown         (<BX) at 40° C./75% RH.     -   10 kGy exposed formulation changed color from yellow (BY1) to         brown (<BO) at 25° C./60% RH, and to dark brown (BX) at 40°         C./75% RH.     -   20 kGy exposed formulation changed color from darker yellow         (>BY1) to brown (<BO) at 25° C./60% RH, and to dark brown (BX)         at 40° C./75% RH.     -   35 kGy exposed formulation changed color from darker yellow         (>BY1) to brown (BO) at 25° C./60% RH, and to dark brown (BX) at         40° C./75% RH.

Potency

Effect of Gamma Irradiation on Formulation A Stability

As shown in Table 5.3, the potency (% LS) of Formulation A at T=0 was affected by gamma irradiation. The % LS of Formulation A was 98.9%, 97.1%, 96.1% and 96.2% after target irradiations of 0, 10, 20 and 35 kGy, respectively.

TABLE 5.3 Potency and Degradation Products Stability Testing for Formulation A Exposed to Nominal Gamma Irradiation Levels of 0, 10, 20 and 35 kGy and Analyzed by HPLC % Mean Degradation Products (all detected peaks) Total 2,6-Dimethylaniline Number of (2,6-DMA) Unknown % Mean Irradiation % (by peak Detected Label Storage Dose Bupivacaine Area ppm (to Peaks Strength Condition Time (kGy)¹ N-oxide Normalization) Bupivacaine)² (each <0.1%) Bupivacaine Initial 0 0 0.27 Not Detected Not Detected 2 peaks 98.9 10 0.43 0.02  75 4 peaks 97.1 20 0.51 0.05 189 9 peaks 96.1 35 0.53 0.08 302 12 peaks 96.2 25° C./60% RH 6 months 0 0.31 Not Detected Not Detected 3 peaks 96.2 10 0.54 0.05 189 6 peaks 96.7 20 0.61 0.06 226 8 peaks 95.8 35 0.60 0.08 302 8 peaks 94.6 20 months 0 0.36 Not Detected Not Detected 5 peaks 98.5 10 0.61 0.03 113 10 peaks 97.5 20 0.70 0.06 226 9 peaks 97.0 35 0.63 0.08 302 10 peaks 96.6 40° C./75% RH 3 months 0 0.23 Not Detected Not Detected 4 peaks 97.1 10 0.47 0.04 151 5 peaks 95.9 20 0.52 0.07 264 7 peaks 95.5 35 0.45 0.09 340 7 peaks 95.3 20 months 0 0.79  0.01⁴  38 10 peaks 97.3 10 0.72 0.04 151 13 peaks 96.8 20 0.57 0.07 264 12 peaks 96.1 35 0.47 0.09 340 12 peaks 96.0 ¹The actual dose range for the nominal 10 kGy exposure was 9.1 to 11.1 kGy, for the nominal 20 kGy exposure it was 19.2 to 22.0 kGy, and for the nominal 35 kGy exposure it was 31.7 to 36.0 kGy. ²Calculation for ppm 2,6-DMA = % 2,6-DMA (by area normalization) × 10000/relative response factor (2.65). This relative response factor was determined for HPLC. Note that the results in this Table are reported as “ppm (to bupivacaine).” To convert from “ppm (to bupivacaine)” to ppm relative to total formulation, the above numbers should be multiplied by 0.12 considering that Formulation A comprises 12 wt % bupivacaine.

Stability at 25° C./60% RH and 40° C./75% RH

No significant changes in % LS were observed for non-irradiated Formulation A and the three groups of irradiated formulations after 20 months storage at 25° C./60% RH compared to their corresponding T=0% LS values. After 20 months at 40° C./75% RH (the commercial product would not be stored under these conditions), the non-irradiated formulation potency decreased from 98.9% to 97.3%, while the gamma irradiated groups had no significant potency changes.

Degradation Products

Irradiation Effect on Formulation A at T=0

The major degradant, bupivacaine N-oxide, is formed by the oxidation of the amine group in bupivacaine. Table 5.3 lists the amounts of 2,6-DMA and bupivacaine N-oxide, and the total number of unknown detected peaks resulting from the gamma irradiation process for all four formulation groups.

2,6-DMA

The results show that for the non-irradiated Formulation A samples, 2,6-DMA was not detected by HPLC. However, as irradiation levels increased, the mean % 2,6-DMA increased to 0.02% (75 ppm) at 10 kGy exposure, 0.05% (189 ppm) at 20 kGy exposure, and 0.08% (302 ppm) at 35 kGy exposure.

Bupivacaine N-Oxide

The irradiation process at T=0 also increased the % bupivacaine N-oxide from 0.27% to 0.43%, 0.51% and 0.53% for samples exposed to 10, 20, and 35 kGy, respectively. The presence of bupivacaine N-oxide was confirmed by matching the retention time with the authentic material.

Total Number of Unknown Detected Peaks

The irradiation process increased the total of unknown degradation peaks (each ≤0.1%) from 2 peaks at 0 kGy to 4, 9, and 12 peaks at 10, 20, and 35 kGy, respectively.

Total Degradation Products

The irradiation process increased the % total degradation products from 0.33% (non-irradiated) to 0.61% (10 kGy exposure), 0.87% (20 kGy exposure), and 0.94% (35 kGy exposure).

Irradiation Effect on Formulation A Stability at 25° C./60% RH

2,6-DMA

The 2,6-DMA was not detected in the non-irradiated Formulation A samples for up to 20 months at 25° C./60% RH (Table 5.3). The levels of 2,6-DMA in the irradiated samples did not significantly change during stability at 25° C./60% RH for up to 20 months.

Bupivacaine N-Oxide

There was a slight increase in the bupivacaine N-oxide by approximately 0.1 to 0.2% for each group after 20 months storage at 25° C./60% RH (Table 5.3).

Total Degradation Products

There was an insignificant increase of approximately 0.1 to 0.2% in the total amount of degradation products in each of the four groups after 20 months at 25° C./60% RH, as compared to the corresponding values at T=0.

Irradiation Effect on Formulation A Stability at 40° C./75% RH

2,6-DMA

The non-irradiated Formulation A samples after 3 months at 40° C./75% RH had no detectable amount of 2,6-DMA (Table 5.3). After 20 months at 40° C./75% RH, the non-irradiated samples had 0.01% (38 ppm) of 2,6-DMA. For the three irradiated groups of samples, the 2,6-DMA increased slightly (0.01 to 0.02%) from their respective T=0 values during storage at 40° C./75% RH. The final levels of 2,6-DMA after 20 months at 40° C./75% RH were 0.04% (151 ppm) in the 10 kGy-exposed samples, 0.07% (264 ppm) in the 20 kGy exposed samples, and 0.09% (340 pm) in the 35 kGy exposed samples.

Bupivacaine N-Oxide

The major degradant, bupivacaine N-oxide, increased from 0.27% to 0.79% in the non-irradiated samples, and increased from 0.43% to 0.72% in the 10 kGy exposed samples after 20-months storage at 40° C./75% RH (Table 5.3). There was no significant change in the bupivacaine N-oxide levels for the 20 and 35 kGy irradiated samples after 20-months at 40° C./75% RH.

Total Degradation Products

The data indicated that the % total degradants increased from 0.33% to 0.99% for the non-irradiated samples, and increased from 0.61% to 1.01% for the 10 kGy irradiated samples, after 20 months at 40° C./75% RH. The total degradants remained the same for the 20 kGy irradiated samples, and appeared to decrease slightly for the 35 kGy irradiated samples after 20 months at 40° C./75% RH.

Potency and Degradation Products at 20 Months

All four groups of Formulation A samples stored at both 25° C./60% RH and 40° C./75% RH for 20 months were also analyzed by HPLC for potency and degradation products. Similar trends in the % LS bupivacaine, % 2,6-DMA, % bupivacaine N-oxide, and % total degradants in the four groups of Formulation A were observed as that by HPLC.

Conclusion

The gamma irradiation exposure levels and storage conditions (temperature and time) affected both the degree of solution coloration and chemical stability of Formulation A. The formulation color changed from light yellow (before irradiation) to yellow (irradiation range 10 to 35 kGy), and to brown/dark brown (under typical stability storage conditions). Acceptable bupivacaine potency stability (% LS) was observed at 25° C./60% RH and 40° C./75% RH for up to 20 months for both the non-irradiated and irradiated samples. The gamma irradiation process induced the potential genotoxic degradant 2,6-DMA.

Example 6

Formulation A was made aseptically by the following process:

1. Add benzyl alcohol to mixing tank and heat to 40° C. (not to exceed 55° C.). 2. While mixing benzyl alcohol under slight vortex, add in pre-weighed bupivacaine base. 3. Mix for not less than 15 minutes. 4. Heat SAIB to approximately 60° C. (not to exceed 93° C.).

5. Weigh in SAIB.

6. Mix for not less than 45 minutes. 7. Perform in-process potency and bioburden testing. 8. Pressurize the tank with nitrogen gas to force the mixture through twin-series, 30″, 0.22 fLm, sterilizing grade filters. 9. Fill the product into 10 mL glass vials. 10. Stopper the vials with 20 mm stoppers under a nitrogen environment. 11. Cap the vials with 20 mm aluminum crimp caps. 12. Inspect each vial. 13. Label and package as appropriate.

Two lots of the resulting formulation had good stability as shown in Table 6.1 and Table 6.2.

TABLE 6.1 Stability Data - Formulation A, Stored at 25° C./60% RH and 40° C./75% RH (7.5 mL) Tests (Acceptance Initial¹ 40° C./75% RH 25° C./60% RH Criteria) 0 1 month 2 months 3 months 3 months Appearance Clear Clear Clear Clear Clear solution solution solution solution solution Assay (Release) ² 98.6 99.1 98.3 97.5 97.6 (95.0-105.0% Label (99.3, 99.4, (99.8, 98.9, 97.1, 98.9, (97.4, 97.4, (97.8, 97.5, Strength) Assay (Shelf-life) ² 98.5, 98.1 98.5) 98.8) 97.6) 97.6) (90.0-105.0% Label 98.5, 98.1) Strength) Individual Degradants³ (Bupivacaine N-oxide ≤2.0%, all other individuals ≤0.2% by Area Normalization) 1) Bupivacaine N-oxide 0.2 0.3 0.3 0.3 0.2 2) 2,6-Dimethylaniline n.d. n.d. n.d. n.d. n.d. Total Degradation Products ⁴ 0.2 0.3 0.3 0.3 0.2 (≤3.0% by Area normalization) Drug Release (Criteria) % Cumulative Release Average (Range)  1 hr (0-10% of 6 (5-6) 5 (5-6) 6 (5-6) 6 (5-7) 6 (5-6) target)  4 hr Report value 17 (15-18) 17 (17-18) 17 (17-17) 17 (17-18) 17 (16-18)  8 hr Report value 26 (23-28) 27 (26-27) 26 (26-27) 27 (26-27) 27 (26-27) 12 hr Report value 37 (32-40) 37 (35-39) 37 (36-39) 35 (34-37) 36 (35-36) 18 hr (40-70% of 54 (49-58) 55 (53-58) 55 (54-57) 51 (48-54) 53 (52-54) target) 24 hr Report value 68 (64-71) 68 (66-71) 67 (65-70) 63 (60-66) 66 (64-68) 36 hr Report value 85 (83-87) 85 (83-86) 85 (83-86)  81 (79-84} 84 (82-86) 48 hr Report value 89 (88-91) 89 (87-90) 89 (87-89) 88 (86-89) 89 (88-90) 72 hr (75-105% of 93 (91-96) 92 (90-94) 92 (89-93) 90 (88-92) 90 (88-92) target) Degree of Coloration BY4 BY2 BY1 Darker than BY2 (Record results) BY1 Volume in Container ⁵ 9.3-9.6 Test not Test not Test not Test not (NLT 7.5 mL) performed performed performed performed Bacteria toxins <24 Test not Test not Test not Test not (≤25 EV/mL); performed performed performed performed Particular Matter, Microscopy (≥10 μm: ≤3000 103, 110 22   4   16   183    particles/vial) (≥25 μm: ≤3000 25, 31 5   1   3   29   particles/vial) Sterility (meets Pass Test not Test not Test not Test not USP/EP) performed performed performed performed ¹Data at T = 0 are average of duplicate sets of samples. All other time points are average of one set of samples. ² Average and individual assay values are reported. ³Average values for degradants are reported. The excipient related degradation products (benzyl acetate and benzyl isobutyrate) are not reported in this table. Not detected(n.d.). ⁴ The total degradation products are based on the sum of all individual degradants at or greater than 0.1%. Average values are reported. ⁵ The range of values is reported.

TABLE 6.2 Stability Data - Formulation A Stored at 25° C./60% RH and 40° C./75% RH (5 mL) Tests (Acceptance Initial¹ 40°^(/)C75% RH Criteria) 0 1 month Appearance Clear solution Clear solution Assay (Release) ² 98.6 (98.9, 98.3, 98.7) 100.0 (101.2, 99.5, 99.4) (95.0-105.0% Label Strength) Assay (Shelf-life) ² (90.0-105.0% Label Strength) Individual Degradants (Bupivacaine N-oxide ≤2.0%, all other individuals ≤0.2% by Area Normalization) 1) Bupivacaine N-oxide 0.1 0.2 2) 2,6-Dimethylaniline n.d. n.d. Total Degradation Products³ 0.1 0.2 (≤3.0% by Area normalization) Drug Release (Criteria) % Cumulative Release Average (Range)  1 hr (0-10% of target) 6 (6-7) 5 (5-7)  4 hr Report value 18 (17-18) 16 (16-17)  8 hr Report value 27 (26-28) 25 (25-26) 12 hr Report value 36 (34-37) 34 (33-34) 18 hr (40-70% of target) 54 (49-58). 55 (53-58) 24 hr Report value 66 (64-69) 63 (62-65) 36 hr Report value 84 (81-87) 82 (80-83) 48 hr Report value 90 (87-93) 87 (85-88) 72 hr (75-105% of target) 92 (88-97) 90 (88-91) Degree of Coloration (Record results) BY4 BY2 Volume in Container ⁴(NLT 7.5 mL) 6.1-6.2 Test not performed Bacteria toxins (≤25 EV/mL); Test not performed Test not performed Particular Matter, Microscopy (≥10 μm: ≤3000 particles/vial) 3, 5 46   (≥25 μm: ≤3000 particles/vial) 1, 2 17   Sterility (meets USP/EP) Test not performed Test not performed ¹Duplicate testing in particular matter were performed and individual values are reported ² Average and individual assay values are reported. ³The total degradation products are based on the sum of all individual degradants at or greater than 0.1%. Average values are reported. ⁴ Range of values is reported from 10 vials.

Example 7

Formulation A was filled into glass vials under a nitrogen atmosphere. The oxygen content of the headspace in the vials was tested.

The data was collected on a Lighthouse Instruments Headspace Oxygen Analyzer Model FMS-760. A summary of the data is presented in the below Table 7.1, which shows the average, standard deviation, and % RSD for each lot (in wt % oxygen). BOR is Beginning of Run, MOR is Middle of Run, and EOR is End of Run indicating when vials were pulled for analysis during the filling run.

TABLE 7.1 Oxygen Headspace Results (%) Lot BOR MOR EOR 1 7.2 6.8 6.9 5.1 6.7 6.2 5.5 6.9 6.6 6.5 6.4 6.3 6.4 6.6 7.3 5.8 7.1 7.5 6.3 6.3 6.0 5.9 7.1 6.3 6.0 7.0 8.5 6.2 6.6 6.9 6.4 7.0 6.7 5.8 6.4 6.5 5.6 6.4 7.4 6.6 6.6 6.6 6.0 7.1 7.1 Average 6.1 6.7 6.9 SD 0.5 0.3 0.6 % RSD 8.4 4.3 9.3 Grand Ave 6.6 Grand SD 0.6 Grand % RSD 9.1 2 5.8 7.7 8.6 7.5 8.0 7.7 7.6 7.8 7.0 6.4 7.1 6.5 7.6 9.4 7.2 7.8 7.4 7.3 7.7 7.4 7.9 6.8 8.3 9.5 6.2 8.2 8.9 7.7 7.4 8.3 6.3 7.1 8.7 6.6 7.5 8.2 7.6 7.3 8.3 7.4 8.5 8.6 7.6 7.0 7.4 Average 7.1 7.7 8.0 SD 0.7 0.6 0.8 % RSD 9.5 8.4 10.2 Grand Ave 7.6 Grand SD 0.8 Grand % RSD 10.5

Example 8

A study was conducted to determine the Appearance, Degree of Coloration of Liquids, Assay, and Degradation Products, including 2,6-Dimethylaniline, formed in Formulation A after exposure to accelerated light per ICH Q1B Guidance for Industry: “Photostability Testing of New Drug Substances and Products”.

Experimental

Option 2 of the ICH Q1B guidance was followed for the accelerated light conditions. Option 2 states that the same sample should be exposed to both the cool white fluorescent and near ultraviolet lamp. The sources of controlled light were: a cool white fluorescent lamp designed to produce an output similar to that specified in ISO 10977 (1993); and a near UV fluorescent lamp having a spectral distribution from 320 nm to 400 nm with a maximum energy emission between 350 nm and 370 nm; a significant proportion of UV should be in both bands of 320 to 360 nm and 360 to 400 nm. Samples were exposed to light providing an overall illumination of not less than 1.2 million lux hours and an integrated near ultraviolet energy of not less than 200 watt hours/square meter.

Three sets of samples, each placed alongside each other, from each lot were exposed to the accelerated light conditions of:

1) Unprotected vials, were directly illuminated. 2) Protected vials, were wrapped in aluminum foil. These were used as dark controls to evaluate the contribution of thermally induced change to the total observed change. 3) Protected vials, were in secondary containers or cartons. These cartons hold 10 vials (in a 2×5 configuration, with a plastic divider separating the two rows) and are composed of white clay coated chipboard of approximate dimensions 2.25×2.25×5.625 inches with a thickness of 0.020 inches. These cartons are from Royal Paper Box Company, Montebello, Calif., who sourced the chipboard material from Clearwater Paper Corporation, Spokane, Wash. using their Candesce CIS stock.

The samples were placed horizontally with respect to the light source.

Stability Results

Tables 8.1 and 8.2 show the photostability results for two different lots of Formulation A. The data in Tables 8.1 and 8.2 show that the amount of 2,6-dimethylaniline ranged from 36.1 to 54.1 ppm in the unprotected vials, far exceeding the specification limit of 10 ppm. The aluminum foil wrapped vials had 2,6-dimethylaniline ranging from 0.4 to 0.6 ppm. The protected vials in cartons had 2,6-dimethylaniline ranging from 1.4 to 1.7 ppm.

The bupivacaine N-oxide degradation product increased to 0.2% in the unprotected vials, but remained below quantitation limit in the aluminum foil wrapped and carton stored vials.

The average bupivacaine assay values were 1.0 to 1.2% higher in the vials stored in the cartons compared to the unprotected vials.

The results in Tables 8.1 and 8.2 shows that a carton can sufficiently protect Formulation A from light induced degradation so the drug product remains within specifications.

TABLE 8.1 Photo stability Data for Formulation A Appearance, Degree of Coloration of Liquids, Assay, Degradation Products, and 2,6-Dimethylaniline Test Results Exposed to Accelerated Light (1,218,060 Lux hrs; 232 W hrs/m²) Protected - Protected - Stored in Test Acceptance Wrapped in Secondary Packaging - Attributes Method Criteria¹ Un-protected Aluminum Foil Unit Dose Carton Appearance Visual Clear light Clear light Clear yellow Clear yellow yellow to yellow liquid; brown liquid; brown liquid; brown liquid; essentially free essentially free essentially free essentially free of particulate of particulate of particulate of particulate matter matter matter matter Degree of EP-2.2.2 ≤6x BY1 BY4 (with yellow BY3 BY3 Coloration of tint) BY4 (with BY3 BY3 Liquids yellow tint) Assay HPLC with 90.0-105.0%    97.2 (97.1, 97.2) 97.8 (97.7, 97.9) 98.4 (98.6, 98.2) UV detector Degradation HPLC with ≤1.0% 0.1 (0.1, 0.1) BQL (BQL, BQL) BQL (BQL, BQL) Bupivacaine UV detector N-oxide Individual ≤0.2% RRT = 0.79; ND ND Unspecified BQL (BQL, BQL) Total Degradation ≤2.0% 0.1 (0.1, 0.1) <0.1 (<0.1, <0.1) <0.1 (<0.1, <0.1) Products Benzyl Acetate ≤20 mg/mL 3.4 (3.4, 3.4) 3.4 (3.4, 3.4) 3.4 (3.4, 3.4) Benzyl ≤10 mg/mL 1.4 (1.4, 1.4) 1.4 (1.4, 1.4) 1.5 (1.5, 1.4) 2.6- HPLC with ≤10 ppm 37.1 (36.1, 38.1) 0.6 (0.5, 0.6) 1.7 (1.7, 1.7) Dimethylaniline Electrochemical detector ¹Acceptance criteria were changed during the development.

TABLE 8.2 Photostability Data for Formulation A Appearance, Degree of Coloration of Liquids, Assay, Degradation Products, and 2,6-Dimethylaniline Test Results Exposed to Accelerated Light (1,218,060 Lux hrs; 232 W hrs/m²) Protected - Protected - Stored in Test Acceptance Wrapped in Secondary Packaging - Attributes Method Criteria Un-protected Aluminum Foil Unit Dose Carton Appearance Visual Clear light Clear light Clear yellow Clear yellow yellow to yellow liquid; brown liquid; brown liquid; brown liquid; essentially essentially free essentially free essentially free free of of particulate of particulate of particulate particulate matter matter matter matter Degree of EP-2.2.2 ≤6x BY1 BY4 (with yellow BY3 BY3 Coloration tint) BY4 (with BY3 BY3 of Liquids yellow tint) Assay HPLC with 90.0-105.0%    98.7 (98.7, 98.7) 99.9 (100.0, 99.7) 99.7 (99.5, 99.8) UV detector Degradation HPLC with ≤1.0% 0.2 (0.2, 0.2) BQL (BQL, BQL) BQL (BQL, BQL) Products UV detector Bupivacaine N- oxide Individual  ≤02% RRT = 0.57; RRT = 0.57; RRT = 0.57; Unspecified BQL (BQL, BQL) BQL (BQL, BQL) BQL (BQL, BQL) Degradants RRT = 0.79; BQL (BQL, BQL) Total Degradation ≤2.0% 0.2 (0.2, 0.2) <0.1 (<0.1, <0.1) <0.1 (<0.1, <0.1) Products Benzyl Acetate ≤20 mg/mL 4.1 (4.1, 4.1) 4.1 (4.1, 4.0) 4.1 (4.1, 4.1) Benzyl Isobutyrate ≤10 mg/mL 1.6 (1.6, 1.6) 1.7 (1.7, 1.7) 1.7 (1.6, 1.7) 2,6- HPLC with ≤10 ppm 53.6 (54.1, 53.1) 0.4 (0.4, 0.4) 1.5 (1.4, 1.5) Dimethylaniline Electrochemical Detector Formulation A should be protected from light, since photostability testing according to ICH Q1B has shown an increase of 2,6-dimethylaniline. The product is packaged in cartons to provide protection from light.

Example 9

Formulation A was tested for 2,6-dimethylaniline by electrochemical detection. For analysis, an aliquot of formulation was diluted 250 times with an aqueous buffer/methanol/acetonitrile diluent. After solubilization of the sample, a small aliquot is transferred into an HPLC vial for analysis using an electrochemical detector.

A series of experiments was conducted examining the effects of amber and red colored glassware on the stability of the 2,6-dimethylaniniline reference standard, using electrochemical detection, at a concentration of 3 ng/mL in an aqueous buffer/methanol solution.

In Experiment 1, the 2,6-dimethylaniline was prepared at a concentration of 3 ng/mL in a clear, colorless glass 100 mL volumetric flask. Aliquots were transferred into clear HPLC glass vials, and assayed against external standards. The 3 injections of the 2,6-dimethylaniline were consistently near 3 ng/mL.

In Experiment 2, the 2,6-dimethylaniline solution at 3 ng/mL prepared in a clear, colorless glass 100 mL volumetric flask was transferred to amber HPLC vials. The 4 samples injected from the amber glass HPLC vials had a 2,6-dimethylaniline content approximately 8 to 12 times higher than the results in Experiment 1.

In Experiment 3, the 2,6-dimethylaniline was prepared at a concentration of 3 ng/mL in a red colored glass 100 mL volumetric flask that had a RAY-SORB® coating to protect from light. An aliquot was transferred into a clear HPLC glass vial, and assayed against external standards. The sample injection had the same 2,6-dimethylaniline concentration value as that in Experiment 1.

In Experiment 4, the 2,6-dimethylaniline solution at 3 ng/mL prepared in the red colored glass 100 mL volumetric flask coated with RAY-SORB® was transferred to an amber HPLC vial. The injected sample from the amber glass HPLC vial had a 2,6-dimethylaniline content approximately 5 times higher than the results in Experiment 1 and Experiment 3.

The conclusion from these experiments is that there is some component from the amber glass HPLC vials that reacts with 2,6-dimethylaniline, creating higher concentrations of 2,6-dimethylaniline, than when the 2,6-dimethylaniline solution is stored in clear glass HPLC vials.

TABLE 9.1 Concentration of 2,6-Dimethlylaniline Standard Stored in Different Color Glassware Color of Observed Experiment Volumetric Color of Concentration of Number Flask HPLC Vial Standard (ng/mL) 1 Clear¹ Clear² 3.0, 3.0, 3.1 2 Clear¹ Amber³ 24.5, 28.4, 34.6, 38.1 3 Red⁴ Clear² 3.0 4 Red⁴ Amber³ 14.9 ¹Clear, colorless, Kimble Glass volumetric flasks, catalog 28014, are manufactured from “33 expansion”, low extractables borosilicate glass, conforming to USP Type 1 and ASTM E438, Type 1, Class A requirements. ²Clear, colorless HPLC vials are from Thermo Fisher Scientific, catalog C40115W. ³Amber HPLC vials are from Agilent Technologies, Part Number: 5182-0545. Amber HPLC vials are manufactured by the addition of metal oxides to clear colorless glass. See Table 9.2 for typical composition of amber and clear glass. ⁴Red colored, Kimble Glass volumetric flasks, catalog 28016, are manufactured from “33 expansion”, low extractables borosilicate glass, conforming to USP Type 1 and ASTM E438, Type 1, Class A requirements, and then RAY-SORB ® processed, which is a proprietary technology providing a consistent, durable, and uniform coating for light protection.

Table 9.2 lists the typical composition of clear and amber glass HPLC vials from Waters Corporation. The use of metal oxides, especially iron oxide and titanium oxide, imparts the amber color to the glass. The presence of these metals in amber glass HPLC vials is the probable reason for the analytically measured amounts of 2,6-dimethylaniline being significantly higher in amber HPLC vials compared to clear, colorless vials (Experiments 2 and 4, in Table 9.1). The results of this experiment suggest that the best way to protect the product from light (to reduce the impurities/degradants) is to fill the formulation into clear vials packaged in boxes or cartons rather than to fill the formulation into amber glass vials.

TABLE 9.2 Chemical Composition (main components in approx. wt %) Type of Glass SiO₂ B₂O₃ Al₂O₃ TiO₂ Fe₂O₃ Na₂O K₂O BaO CaO Amber “51 69 10 6 3 1 6 2 2 0.5 expansion” Clear “33 80 11 7 — — 7 2 <0.1 0.5 expansion”

Example 10 Summary

The purpose of this study was to evaluate the compatibility of Formulation A with three different types of coated serum 20 mm, 4432/50 gray chlorobutyl rubber stoppers from West Pharmaceutical Services (West). The results of this study support the selection of the stopper that has FluroTec® coated on the top and bottom surfaces, West part number 19700038 (Drawing No. WS-792).

Background

Formulation A was filled into vials that were stoppered with 20 mm, Teflon faced, 4432/50 gray chlorobutyl rubber serum stoppers from West (part number 10144806) as part of the primary closure system. The Teflon face was in contact with the formulation. The manufacturing process was on a small scale, and the stoppers were manually inserted into the vials and crimped sealed. This stopper would need to be siliconized to allow for its use in high speed filling lines at a commercial facility because the top and edges of the stopper are not lubricated. The standard siliconization process for stoppers can introduce extractable silicone oil into the finished product, since silicone oil is readily soluble in Formulation A. Therefore, three other kinds of chemically resistant stoppers from West were evaluated that would be more appropriate for use at a commercial facility and would not require siliconization since they have various coatings on both the top and bottom surfaces.

The first serum stopper selected for study was coated with FluroTec on both surfaces, West part number 19700038 (20 mm, 4432/50 gray chlorobutyl rubber; Drawing No. WS-792). The FluroTec film was applied during the molding process of the stopper to the top (flange) and to the bottom (plug) surfaces of the stopper. FluroTec film provides an effective barrier against organic and inorganic stopper extractables to minimize interactions between the drug formulation and closure. The proprietary fluorocarbon film, made from a modified ethylene-tetrafluoroethylenene (ETFE) copolymer, also reduces the sorption of the drug product. In addition, the low surface energy of the FluroTec film provides sufficient lubricity, such that siliconization of the stopper is not needed, thus eliminating a potential source of contamination.

The second and third kinds of serum stoppers used in this study had another type of coating available from West, called B2-coating. The B2-coating is a cross-linkable high molecular weight polydimethylsiloxane coating that is applied to the surface of rubber stoppers. The B2-coating process minimizes the transfer of silicone oil into drug solutions. It also eliminates the need for conventional siliconization to facilitate manufacturing of the product. The B2 coated stoppers evaluated in this study only had the top surfaces coated to the maximum level (level 4), while the bottom surfaces were not coated (level 0). The West nomenclature used to describe the kind of coating applied to the stoppers in this study is B2-40. This B2-40 coating was applied to stoppers that had either a Teflon or a FluroTec coating on the bottom (plug) face. The Teflon and FluroTec coatings are similar, but not identical fluorinated copolymers. The stopper with B2-40 on the top with Teflon on the bottom is West part number 10144942 (20 mm, 4432/50 gray chlorobutyl rubber, Drawing No. WS-577), and the stopper with B2-40 on the top with FluroTec on the bottom is West part number 19700022 (20 mm, 4432/50 gray chlorobutyl rubber, Drawing No. WS-791). Although the amount of extractable silicone oil was significantly reduced with the B2 process, there were still measurable extractables. Because the stoppers were washed and sterilized in bulk, the B2-40 coating on the top of stoppers are randomly in contact with the bottom of other stoppers. Therefore there was the potential for silicone oil transfer onto the FluroTec and Teflon plug faces of these B2-40 coated stoppers, and thus transfer into the product.

Experimental Methods

Formulation Composition and Container/Closure System

Formulation A was prepared with bupivacaine base at 12% w/w, SAIB at 66% w/w, and benzyl alcohol at 22% w/w. The lot was filtered and filled (˜8 mL each) into approximately 600 Type 1 10 mL glass vials.

About 200 vials were stoppered with each of the three different kinds of 20 mm stoppers from West. Table 10.1 summarizes the lot information for each set of packaged product. Aluminum crimp seals were used to seal the product. To simulate the anticipated aseptic manufacturing process, the filled, stoppered vials were not terminally sterilized by gamma irradiation.

TABLE 10.1 Formulation A Packaged Lot and Packaging Information Description of the Coated Formulation A Stoppers for Each Lot Lot Number Top (Flange)/Bottom (Plug) 6.1 FluroTec/FluroTec 6.2 B2-40/Teflon 6.3 B2-40/FluroTec

Stability Procedure

Ninety three (93) product filled vials of each kind of stopper were labeled and packaged in secondary containers (corrugated cartons), and placed on stability in the inverted position at 25° C./60% RH and 40° C./75% RH.

The analytical tests for the stability studies included appearance, identity, potency and related substances/degradation products. The identity test was performed at the initial time point only.

At the initial time point, two vials were used for assay and degradants testing instead of three vials. This did not impact the quality of the data in this study.

Although the study was set up with the intention to conduct testing up to 12 months at 25° C./60% RH, the study was stopped after analysis of the 6 months stability samples. The stability data for up to 6 months at both 25° C./60% RH and 40° C./75% RH were deemed sufficient to draw conclusions about the compatibility of Formulation A with the three different stoppers.

Visual appearance testing was only performed at initial and 1 month, and particulate matter testing (USP <788>) was only performed at 1 and 3 months. The practice during preparation of assay samples was to visually confirm a clear solution, free of particulates. These observations were not documented since they were as expected.

A visual color assessment test using EP 2.2.2 color standards of the brown yellow (BY series, 2 mL ampoules from Fluka) was added at initial and at 1 month (25° C./60% RH and at 40° C./75% RH). This test was discontinued after 1 month since the sample color was darker than BY1, which is the darkest in the set. The test was conducted by one analyst with confirmation of the visual color assessment by a second analyst. To conduct the test, 1 mL of formulation was transferred into a clear 1.8 mL HPLC glass vial and it was measured under ambient laboratory light against commercial color standards in 2 mL glass ampoules. The inner diameter, or light pathlength, of the 2 mL ampoules (9.53 mm) for the standards was essentially the same as that of the 1.8 mL glass vials (10.03 mm) used for the samples.

Results and Discussion

Tables 10.2 and 10.3 list the results for the three different types of stopper. Testing included visual appearance, solution color by EP 2.2.2 (brown yellow, BY series), assay and degradants by HPLC, and particulate matter by microscopy (USP <788>). For ease of comparison of the stopper data, Table 10.4 summarizes the average % LS bupivacaine, the % remaining bupivacaine relative to the initial values, the % bupivacaine N-oxide and the total % degradants.

TABLE 10.2 Stability Data at 25° C./60% RH for Stoppers with Formulation A Stopper Top/Bottom 25° C./60% RH Attribute Method Coatings Initial 1 Month 3 Months 6 Months Appearance¹ Visual FluroTec/ Clear light Clear brown not determined not determined (EP 2.2.2) FluroTec yellow liquid. yellow liquid not determined not determined (Darker than (BY3) BY5) B2-40/ Clear light Clear brown not determined not determined Teflon yellow liquid. yellow liquid not determined not determined (Darker than (BY3) BY5) B2-40/ Clear light Clear brown not determined not determined FluroTec yellow liquid. yellow liquid not determined not determined (Darker than (BY3) BY5) Identity HPLC All Stoppers Bupivacaine is not not determined not determined present determined Assay HPLC FluroTec/ 100.9% LS 100.5% LS 99.5% LS 102.2% LS FluroTec (101.5, 100.2) (100.4, 100.7, (99.9, 98.9, (101.6, 102.4, 100.4) 99.7) 102.7) B2-40/ 99.8% LS 99.8% LS 98.3% LS 100.2% LS Teflon (99.7, 99.8) (100.3, 99.5, (99.2, 98.1, (100.2, 100.2, 99.5) 97.5) 100.2) B2-40/ 101.5% LS 99.3% LS 99.4% LS 100.3% LS FluroTec (101.5, 101.4) (99.4, 99.4, (99.7, 98.5, (100.5, 100.3, 99.1) 99.9) 100.1) Degradation HPLC FluroTec/ % Bupivacaine % Bupivacaine % Bupivacaine % Bupivacaine Products FluroTec N-oxide N-oxide N-oxide N-oxide 0.2% (0.2%, 0.1% (0.1%, 0.2% (0.2%, 0.2% (0.2%, 0.2%) 0.1%, 0.1%) 0.2%, 0.2%) 0.2%, 0.2%) Unknown Unknown Unknown Unknown RRT = 0.24 RRT = 0.24 RRT = 0.28 RRT = 0.28 0.05-0.06% 0.04-0.04% 0.04-0.05% 0.05-0.05% B2-40/ % Bupivacaine % Bupivacaine % Bupivacaine % Bupivacaine Teflon N-oxide N-oxide N-oxide N-oxide 0.1% (0.1%, 0.1% (0.1%, 0.2% (0.2%, 0.2% (0.2%, 0.2%) 0.1%, 0.1%) 0.2%, 0.2%) 0.2%, 0.2%) Unknown Unknown Unknown Unknown RRT = 0.24 RRT = 0.24 RRT = 0.28 RRT = 0.28 0.04-0.06% 0.04-0.04% 0.04-0.04% 0.05-0.05% B2-40/ % Bupivacaine % Bupivacaine % Bupivacaine % Bupivacaine FluroTec N-oxide 0.1% N-oxide N-oxide N-oxide (0.1%, 0.1%) 0.1% (0.1%, 0.2% (0.2%, 0.2% (0.2%, Unknown 0.1%, 0.1%) 0.2%, 0.2%) 0.2%, 0.2%) RRT = 0.24 Unknown Unknown Unknown 0.04-0.04% RRT = 0.24 RRT = 0.28 RRT = 0.28 0.04-0.05% 0.05-0.05% 0.05-0.05% Particulate USP FluroTec/ Not Not ≥10 μm ≥10 μm Matter <788> FluroTec Determined Determined particles/vial: 30 particles/vial: 18 ≥25 μm ≥25 μm particles/vial: 3 particles/vial: <10² B2-40/ Not Not ≥10 μm ≥10 μm Teflon Determined Determined particles/vial: 57 particles/vial: 42 ≥25 μm ≥25 μm particles/vial: 3 particles/vial: 3 B2-40/ Not Not ≥10 μm ≥10 μm FluroTec Determined Determined particles/vial: 45 particles/vial: 42 ≥25 μm ≥25 μm particles/vial: <10² particles/vial: 9 ¹Clear liquid, free of particulate matter, yellow to brown. In addition to the visual appearance test, a visual color assessment using EP color standards of the BY series was also performed and verified by a second analyst. The color result is for information only. ²A value of <10 indicates that no particles were detected.

TABLE 10.3 Stability Data at 40° C./75% RH for Stoppers with Formulation A Stopper Coatings 40° C./75% RH % Attributes Method Top/Bottom Initial 1 Month 3 Months 6 Months Appearance¹ Visual FluroTec/ Clear light Clear brown not determined not determined (EP 2.2.2) FluroTec yellow liquid. yellow liquid not determined not determined (Darker than (BY2) BY5) B2-40/ Clear light Clear brown not determined not determined Teflon yellow liquid. yellow liquid not determined not determined (Darker than (BY2) BY5) B2-40/ Clear light Clear brown not determined not determined FluroTec yellow liquid. yellow liquid not determined not determined (Darker than (BY2) BY5) Assay HPLC FluroTec/ 100.9% ES 98.0% LS 99.2% LS 100.9% LS FluroTec (101.5, 100.2) (100.3, 99.6, (99.6, 98.8, (100.6, 100.4, 92.6², 98.1², 99.2) 101.6) 98.0, 99.2)² B2-40/ 99.8% LS 99.1% LS 99.0% LS 100.6% LS Teflon (99.7, 99.8) (99.9, 98.5, (98.9, 97.9, (99.7, 100.9, 98.9) 100.2) 101.1) B2-40/ 101.5% LS 99.1% LS 98.2% LS 100.7% LS FluroTec (101.5, 101.4) (99.0, 99.1, (98.1, 98.1, (100.3, 101.3, 99.3) 98.4) 100.6) Degradation HPLC FluroTec/ % Bupivacaine % Bupivacaine % Bupivacaine % Bupivacaine Products FluroTec N-oxide N-oxide N-oxide N-oxide 0.2% (0.2%, 0.1% (0.1%, 0.3% (0.3%, 0.3% (0.3%, 0.2%) 0.1%, 0.1%) 0.3%, 0.2%) 0.3%, 0.3%) Unknown Unknown Unknown Unknown RRT = 0.24 RRT = 0.24 RRT = 0.28 RRT = 0.28, 0.05-0.06% 0.04-0.04% 0.04-0.05% RRT = 0.30 0.05-0.05%; 0.01-0.02% B2-40/ % Bupivacaine % Bupivacaine % Bupivacaine % Bupivacaine Teflon N-oxide N-oxide N-oxide N- oxide 0.1% (0.1%, 0.1% (0.1%, 0.3% (0.3%, 0.3% (0.3%, 0.2%) 0.1%, 0.1%) 0.3%, 0.3%) 0.3%, 0.3%) Unknown Unknown Unknown Unknown RRT = 0.24 RRT = 0.24 RRT = 0.28 RRT = 0.28, 0.04-0.06% 0.04-0.04% 0.04-0.05% RRT = 0.30 0.05-0.05%; 0.02-0.02% B2-40/ % Bupivacaine % Bupivacaine % Bupivacaine % Bupivacaine FluroTec N-oxide N-oxide N-oxide N-oxide 0.1% 0.1% (0.1%, 0.3% (0.3%, 0.3% (0.3%, (0.1%, 0.1%) 0.1%, 0.1%) 0.3%, 0.3%) 0.3%, 0.3%) Unknown Unknown Unknown Unknown RRT = 0.24 RRT = 0.24 RRT = 0.28 RRT = 0.28, 0.04-0.04% 0.04-0.05% 0.05-0.05% RRT = 0.30 0.04-0.05%; 0.01-0.02% Particulate USP FluroTec/ Not ≥10 μm ≥10 μm ≥10 μm Matter <788> FluroTec Determined particles/vial: 10 particles/vial: 48 particles/vial: 18 ≥25 μm ≥25 μm ≥25 μm particles/vial: <50 particles/vial: <10³ particles/vial: <10 B2-40/ Not ≥10 μm ≥10 μm ≥10 μm Teflon Determined particles/vial: 10 particles/vial: 45 particles/vial: 36 ≥25 μm ≥25 μm ≥25 μm particles/vial: <50 particles/vial: 3 particles/vial: <10 B2-40/ Not ≥10 μm ≥10 μm ≥10 μm FluroTec Determined particles/vial: 25 particles/vial: 39 particles/vial: 93 ≥25 μm ≥25 μm ≥25 μm particles/vial: <50 particles/vial: <10 particles/vial: 3 ¹Clear liquid, free of particulate matter, yellow to brown. In addition to the visual appearance test, a visual color assessment using EP color standards of the BY series was also performed and verified by a second analyst. The color result is for information only. ²The initial value from vial #3 was 92.6%. Because of this out of trend result, another sample was prepared from the same vial, giving a value of 98.1%. During the retest of vial #3, two new vials were sampled and tested. Thus a total of five vials were tested, of which two samples came from vial #3. All six assay values from the five vials are reported, and the resulting average was 98.0%. ³A value of <10 indicates that no particles were detected.

TABLE 10.4 Chemical Compatibility of Formulation A Packaged with Three Different Types of Stoppers at 25° C./60% RH and 40° C./75% RH for up to 6 Months Stopper Coatings Top/Bottom FluroTec/FluroTec B2-40/Teflon B2-40/FluroTec Storage % Re- % % Total % Re- % % Total % Re- % % Total Conditions Month % LS maining N-oxide Degradants % LS maining N-oxide Degradants % LS maining N-oxide Degradants Initial 0 100.9 100.0 0.2 0.2 99.8 100.0 0.1 0.1 101.5 100.0 0.1 0.1 25° C./ 1 100.5 99.6 0.1 0.1 99.8 100.0 0.1 0.1 99.3 97.8 0.1 0.1 60% RH 3 99.5 98.6 0.2 0.2 98.3 98.5 0.2 0.2 99.4 97.9 0.2 0.2 6 102.2 101.3 0.2 0.2 100.2 100.4 0.2 0.2 100.3 98.8 0.2 0.2 40° C./ 1 98.0 97.1 0.1 0.1 99.1 99.3 0.1 0.1 99.1 97.6 0.1 0.1 75% RH 3 99.2 98.3 0.3 0.3 99.0 99.2 0.3 0.3 98.2 96.7 0.3 0.3 6 100.9 100.0 0.3 0.3 100.6 100.8 0.3 0.3 100.7 99.2 0.3 0.3

Appearance and Solution Color

The visual appearance of all the samples with different types of stoppers were “clear light yellow liquid” at initial, “clear brown yellow liquid” at 1 month for 25° C./60% RH, and “clear brown yellow liquid” at 1 month for 40° C./75% RH. Using EP 2.2.2 BY color standards (color increases from BY7 to BY1), all the samples at initial were darker than BY5, at 1 month at 25° C./60% RH they were BY3, and at 1 month at 40° C./75% RH they were BY2. The product's color increased as a function of storage temperature and time. The different types of stoppers did not affect the visual appearance of product.

Particulate Matter

Particulate matter was tested by the microscopic method (USP<788>), and the data were similar among the three types of stoppers at 25° C./60% RH for 3 and 6 months (Table 10.2), and at 40° C./75% RH for 1, 3 and 6 months (Table 10.3). The data were significantly below the small volume parenteral specifications of: ≥10 μm: ≤3000 particles/vial and ≥25 μm: ≤300 particles/vial.

Assay and Degradants

The % LS bupivacaine data was similar for each of the type of stoppers after 6 months at both 25° C./60% RH and 40° C./75% RH. Bupivacaine N-oxide (the major product degradant) exhibited similar minor increases over time at 25° C./60% RH and 40° C./75% RH for each of the stoppers. The unknown degradant profiles at RRT 0.24, 0.28, and 0.30 was the same for all three types of stoppers through 6 months at 25° C./60% RH and 40° C./75% RH.

A review of the data summarized in Table 10.4 indicates that there are no formulation stability differences between the stoppers.

Conclusions

In conclusion, the three stoppers had similar physical and chemical performances with Formulation A. Although the B2-40 process is a way of applying a more controlled, less amount of silicone than conventional siliconization, the potential still exists for some extractable silicone to be solubilized in the formulation due to the presence of benzyl alcohol. Therefore, the recommendation is to pursue the FluroTec/FluroTec stopper, since this will avoid the use of any type of silicone, including B2.

Example 11

Sucrose acetate isobutyrate was tested for metal content as follows. The sample was prepared with a 0.1 g weighed portion mixed with 2 mL nitric acid and 0.5 mL hydrochloric acid for 1 hour on a block digestor set at 110° C. After cooling, 0.5 mL of 30% hydrogen peroxide was added, and the digestion resumed for 30 minutes (the material appeared dissolved). After cooling, internal standard solution was added and dilution with purified water to 20 g produced a solution for ICP-MS analysis. The results are shown below:

Detectio Detection Element ppm Limit Element ppm Limit Aluminum ND 0.8 Molybdenum ND 0.02 Antimony ND 0.02 Neodymium ND 0.02 Arsenic ND 0.02 Nickel ND 0.02 Barium ND 0.02 Niobium ND Beryllium ND 0.02 Osmium ND Bismuth ND 0.02 Palladium ND 0.06 Boron ND 0.5 Phosphorus ND 2 Bromine ND 2 Platinum ND 0.02 Cadmium ND 0.02 Potassium ND 5 Calcium ND Praseodymium ND 0.02 Cerium ND 0.02 Rhenium ND 0.02 Cesium ND 0.02 Rhodium ND 0.02 Chromium ND 0.2 Rubidium ND 0.02 Cobalt ND 0.8 Ruthenium ND 0.03 Copper ND 0.3 Samarium ND 0.02 Dysprosium ND 0.02 Selenium ND 0.1 Erbium ND 0.02 Silver ND 0.02 Euronium ND 0.02 Sodium ND 8 Gadolinium ND 0.02 Strontium ND 0.08 Gallium ND 0.02 Tantalum ND Germanium ND 0.02 Tellurium ND 0.02 Gold 0.4 0.02 Thallium ND 0.2 Hafnium ND 0.02 Thorium ND 0.03 Holmium ND 0.02 Thulium ND 0.02 Iodine ND Tin 0.0 0.04 Iridium ND 0.05 Titanium ND 0.2 Iron 2   1 Tungsten ND Lanthanum ND 0.02 Uranium ND 0.02 Lead ND 0.02 Vanadium ND 0.06 Lithium ND 0.02 Ytterbium ND 0.02 Lutetium ND 0.1 Yttrium ND 0.04 Magnesium ND 1 Zinc ND Manganese ND 0.04 Zirconium ND Mercury ND 0.1

Formulation A was compounded using steel compounding tanks. Silicone tubing was used to transfer Formulation A. Formulation A was filled into glass vials, which were then sealed with fluorocarbon-coated stoppers.

Formulation A was tested for metal content as follows. The sample was prepared with a 0.2 g weighed portion mixed with 2 mL nitric acid, 1 mL hydrochloric acid, and 1 mL hydrofluoric acid, then digested in a closed-vessel microwave system (the material appeared dissolved). After cooling, internal standard solution was added and dilution with purified water to 50 g produced a solution for ICP-MS analysis. The results are shown below:

Detectio Detection Element ppm Limit Element ppm Limit Aluminum ND 0.6 Molybdenum ND 0.02 Antimony ND 0.03 Neodymium ND 0.02 Arsenic ND 0.07 Nickel ND 0.02 Barium ND 0.02 Niobium ND 0.6 Beryilium ND 0.02 Osmium ND 0.2 Bismuth ND 0.02 Palladium ND 0.02 Boron ND 0.2 Phosphorus ND 5 Bromine ND 1000 Platinum ND 0.02 Cadmium ND 0.02 Potassium ND 10 Calcium ND 2 Praseodymium ND 0.02 Cerium ND 0.02 Rhenium ND 0.02 Cesium ND 0.02 Rhodium ND 0.02 Chromium ND 0.07 Rubidium ND 0.02 Cobalt ND 0.02 Ruthenium ND 0.02 Copper ND 0.04 Samarium ND 0.02 Dysprosium ND 0.02 Selenium ND 0.1 Erbium ND 0.02 Silver ND 0.02 Europium ND 0.02 Sodium ND 6 Gadolinium ND 0.02 Strontium ND 0.02 Gallium ND 0.02 Tantalum ND 20 Germanium ND 0.02 Tellurium ND 0.02 Gold ND 0.07 Thallium ND 0.02 Hafnium ND 0.05 Thorium ND 0.03 Holmium ND 0.02 Thulium ND 0.02 Iodine ND 0.1 Tin ND 0.02 Iridium ND 0.02 Titanium ND 0.05 Iron ND 1 Tungsten ND 0.5 Lanthanum ND 0.02 Uranium ND 0.02 Lead ND 0.02 Vanadium ND 0.02 Lithium ND 0.04 Ytterbium ND 0.02 Lutetium ND 0.5 Yttrium ND 0.02 Magnesium ND 1 Zinc ND 2 Manganese ND 0.02 Zirconium ND 0.1 Mercury ND 0.04

Example 12

Formulation A and placebo compositions were evaluated for water content. Formulation A in this study included 12% w/w bupivacaine, 66% w/w sucrose acetate isobutyrate (SAIB), and 22% w/w benzyl alcohol, as described above. Placebo compositions were composed of 75% w/w sucrose acetate isobutyrate (SAIB), and 25% w/w benzyl alcohol.

Filters used during aseptic preparation of Formulation A and placebo compositions can include residual water content resulting in compositions having a detectable amount of water. To ensure that water content is minimized or altogether absent from prepared bupivacaine compositions, filters used during aseptic preparation are: 1) tested for integrity by measuring the bubble point of the filter with pressurized sterile water for injection; 2) purged with nitrogen for not less than 5 minutes at 50 psi to remove any residual water in the filter; and 3) bupivacaine composition (e.g., Formulation A containing 12% w/w bupivacaine or placebo composition) is flushed through the filter with the filtrate being discarded. In this example, not less than 6 liters of Formulation A was flushed through the filters before collecting sample composition into vials.

The water content in sample vials collected at the beginning, middle and end of the collection process was evaluated. The water content of the collected sample vials was compared to the water content of bupivacaine composition in the filtrate flushed through the filters. Historical water content from sample vials collected during previous sample preparation runs was also compared.

Methods Materials

1) Placebo Composition

-   -   Preparation Filter flushes (1 L, 2 L, 3 L, 4 L, 5 L, and 6 L),         and vials from the Beginning, Middle, and End of Run

2) Formulation A— Sample 1

-   -   Preparation Filter flushes (1 L, 2 L, 3 L, 4 L, 5 L, and 6 L),         and vials from the Beginning, Middle, and End of Run

3) Formulation A— Sample 2

-   -   Preparation Filter flushes (1 L, 2 L, 3 L, 4 L, 5 L, 6 L, 7 L, 8         L, 9 L, and 10 L); and vials from the Beginning, Middle, and End         of Run.

4) Vials from Formulation A: A1, B1, C1, D1, E1, F1, G1, and H1, and I1.

5) Vials from placebo composition A

Water Content Testing

Samples were tested according to USP <921>, Method 1c, using an EM Science Aquastar C3000 Coulometric Titrator. Due to the high viscosity of the formulation, the samples required dilution with methanol prior to introduction into the Coulometric Titrator. Approximately 0.5 g of Formulation A or placebo composition was accurately weighed into a 10 mL vial. An approximately equal amount of methanol was added and the weight accurately recorded. If a sample, such as the manufacturing line flushes, was known to have a high amount of water, then proportionally more methanol was mixed with the sample. Each vial was then sealed and shaken vigorously for at least 30 seconds.

Approximately 0.5 g of the sample/methanol mixture was delivered into the Coulometric Titrator by liquid injection. The syringe used to deliver the sample was weighed before and after injection to determine the amount assayed.

Results Placebo Composition

Table 12.1 summarizes the water content results for the 6 one-liter preparation filter flushes for placebo composition. Each one liter of flush was typically tested in duplicate; with the results being very consistent. The first one liter of product flush was essentially all water. Subsequent flushes steadily reduced the water content to approximately 0.58% by the 6^(th) liter. Table 12.2 shows the water content of the finished placebo composition in vials collected from the beginning, the middle, and the end of the filling process. Each vial was assayed in duplicate, with the results being very consistent. The average vial water content results in Table 12.2 were approximately 0.35% for the beginning, 0.19% for the middle, and 0.30% for the end of filling.

TABLE 12.1 Water Content in Preparation Filter Flushes of placebo composition determined by Karl Fischer Titration % Water Content (Typically Two % Water Content Flush Injections per (Average for Fraction Sample ID Flush Fraction) Flush Fraction) 1^(st) Liter Placebo-1L-1 96.4341 96.4341 2^(nd) Liter Placebo-2L-1 2.3669 2.3641 Placebo-2L-2 2.3613 3^(rd) Liter Placebo-3L-1 1.0225 1.0290 Placebo-3L-2 1.0354 4^(th) Liter Placebo-4L-1 0.8726 0.8825 Placebo-4L-2 0.8924 5^(th) Liter Placebo-5L-1 0.7625 0.7607 Placebo-5L-2 0.7588 6^(th) Liter Placebo-6L-1 0.5669 0.5821 Placebo-6L-2 0.5972

TABLE 12.2 Water Content in placebo composition samples by Karl Fischer Titration % Water % Water % Water Location Content (Two Content Content of Vial Injections (Vial (Location from Lot Sample ID per Vial) Average) Average) Beginning Placebo-BOR-1-1 0.2970 0.2918 0.3496 of Run (BOR) Placebo-BOR-1-2 0.2866 Placebo-BOR-2-1 0.4125 0.4075 Placebo-BOR-2-2 0.4024 Middle of Placebo-MOR-1-1 0.1997 0.1926 0.1906 Run (MOR) Placebo-MOR-1-2 0.1854 Placebo-MOR-2-1 0.1940 0.1887 Placebo-MOR-2-2 0.1833 End of Placebo-EOR-1-1 0.4165 0.4103 0.3022 Run (EOR) Placebo-EOR-1 -2 0.4040 Placebo-EOR-2-1 0.2037 0.1942 Placebo-EOR-2-2 0.1847

Formulation A—Sample 1

Table 12.3 summarizes the water content results for the 6 one-liter preparation filter flushes for Formulation A. Testing was done in the same manner as for the placebo compositions. The first one liter of product flush was essentially all water. Subsequent flushes steadily reduced the water content to approximately 1.06% by the 6^(th) liter. Table 12.4 shows the water content of the finished product in vials collected from the beginning, the middle, and the end of the filling process. The average vial water content results in Table 12.4 were approximately 0.35% for the beginning, 0.11% for the middle, and 0.11% for the end of filling.

TABLE 12.3 Water Content in Preparation Filter Flushes of bupivacaine composition - Sample 1 determined by Karl Fischer Titration % Water Content (Typically Two % Water Content Flush Injections per (Average for Fraction Sample ID Flush Fraction) Flush Fraction) 1^(st) Liter Bupivacaine S1-1L-1 96.9996 96.9996 2^(nd) Liter Bupivacaine S1-2L-1 2.4935 2.5835 Bupivacaine S1-2L-2 2.6734 3^(rd) Liter Bupivacaine S1-3L-1 2.0673 2.0556 Bupivacaine S1-3L-2 2.0438 4^(th) Liter Bupivacaine S1-4L-1 1.6314 1.6156 Bupivacaine S1-4L-2 1.5997 5^(th) Liter Bupivacaine S1-5L-1 1.1264 1.1270 Bupivacaine S1-5L-2 1.1275 6^(th) Liter Bupivacaine S1-6L-1 1.0605 1.0559 Bupivacaine S1-6L-2 1.0512

TABLE 12.4 Water Content in sustained release bupivacaine composition samples - Sample 1 by Karl Fischer Titration % Water % Water % Water Content (Two Content Content Injections (Vial (Location Vial ID Sample ID per Vial) Average) Average) Beginning Bupivacaine S1-BOR-1-1 0.3123 0.3102 0.3467 of Run Bupivacaine S1-BOR-1-2 0.3080 Bupivacaine S1-BOR-2-1 0.3808 0.3833 Bupivacaine S1-BOR-2-2 0.3858 Middle Bupivacaine S1-MOR-1-1 0.1083 0.1096 0.1119 of Run Bupivacaine S1-MOR-1-2 0.1108 Bupivacaine S1-MOR-2-1 0.1114 0.1143 Bupivacaine S1-MOR-2-2 0.1171 End Bupivacaine S1-EOR-1-1 0.1105 0.1099 0.1058 of Run Bupivacaine S1-EOR-1-2 0.1092 Bupivacaine S1-EOR-2-1 0.1020 0.1018 Bupivacaine S1-EOR-2-2 0.1016

Formulation A—Sample 2

The objective of the evaluation was to examine if the water content between the last liter of flush could be more consistent with the values obtained in the vials from the beginning of the filling process. For Formulation A, Sample 2, the nitrogen pressure was increased from 50 to 55 psi, and was blown through the filters for not less than 5 minutes. In addition, 10 liters of formulation was flushed through the filters instead of 6 liters as in the previous lots.

The water content for these 10 liters of flushes for Formulation A, Sample 2 is shown in Table 12.5. The 1^(st) one liter of flush started at approximately 2.41% water. This is in contrast to the placebo compositions and Formulation A, Sample 1 (Tables 12.1 and 12.3, respectively) which were greater than 99% water. The increased pressure of the nitrogen purging step of the filters for Sample 2 resulted in less water in the filters prior to flushing the product through it. The water content steadily decreased with the number of flushes, with 0.39% water detected in the 10^(th) one-liter flush. Table 12.6 shows that the average water content of the finished product in vials collected from the beginning, the middle, and the end of the filling process were 0.20%, 0.08%, and 0.06%, respectively.

TABLE 12.5 Water Content in Preparation Filter Flushes of placebo composition - Sample 2 determined by Karl Fischer Titration % Water Content % Water Content Flush (Two Injections per (Average for Fraction Sample ID Flush Fraction) Flush Fraction) 1^(st) Liter Bupivacaine S2 1L Flush-1 2.3215 2.4076 Bupivacaine S2 1L Flush-2 2.4936 2^(nd) Liter Bupivacaine S2 2L Flush-1 2.0838 2.0499 Bupivacaine S2 2L Flush-2 2.0159 3^(rd) Liter Bupivacaine S2 3L Flush-1 1.1442 1.1378 Bupivacaine S2 3L Flush-2 1.1313 4^(th) Liter Bupivacaine S2 4L Flush-1 0.7282 0.7327 Bupivacaine S2 4L Flush-2 0.7371 5^(th) Liter Bupivacaine S2 5L Flush-1 0.6185 0.6153 Bupivacaine S2 5L Flush-2 0.6120 6^(th) Liter Bupivacaine S2 6L Flush-1 0.5543 0.5528 Bupivacaine S2 6L Flush-2 0.5513 7^(th) Liter Bupivacaine S2 7L Flush-1 0.4848 0.4892 Bupivacaine S2 7L Flush-2 0.4936 8^(th) Liter Bupivacaine S2 8L Flush-1 0.4748 0.4730 Bupivacaine S2 8L Flush-2 0.4712 9^(th) Liter Bupivacaine S2 9L Flush-1 0.3413 0.3477 Bupivacaine S2 9L Flush-2 0.3541 10^(th) Liter Bupivacaine S2 10L Flush-1 0.3960 0.3949 Bupivacaine S2 10L Flush-2 0.3937

TABLE 12.6 Water Content in Formulation A - Sample 2 determined by Karl Fischer Titration % Water % Water % Water Location of Content (Two Content Content Vial from Injections (Vial (Location the Lot Sample ID per Vial) Average) Average) Beginning Bupivacaine S2 BOR-1-1 0.1840 0.1840 0.2024 of Run Bupivacaine S2 BOR-1-2 0.1840 Bupivacaine S2 BOR-2-1 0.2202 0.2208 Bupivacaine S2 BOR-2-2 0.2214 Middle of Bupivacaine S2 MOR-1-1 0.0841 0.0849 0.0839 Run Bupivacaine S2 MOR-1-2 0.0857 Bupivacaine S2 MOR-2-1 0.0840 0.0830 Bupivacaine S2 MOR-2-2 0.0819 End of Run Bupivacaine S2 EOR-1-1 0.0652 0.0648 0.0640 Bupivacaine S2 EOR-1-2 0.0643 Bupivacaine S2 EOR-2-1 0.0638 0.0633 Bupivacaine S2 EOR-2-2 0.0627

Although the data shows the changes in the preparation process (increased nitrogen pressure and larger volume of product flush) were effective in reducing the water content in Formulation A, the results for the filled vials did not appear to be practically different from the prior drying process.

ICH and Prior Clinical Lots of Formulation A

Table 12.7 summarizes the water content results for the 4 ICH lots (each with fill sizes of 5 mL and 7.5 mL) and the 2 clinical lots (Formulation A and a placebo) manufactured previously. These lots were manufactured with a nitrogen purge of the filters at 50 psi for not less than 5 minutes with not less than 6 L flush of product. Two or four vials from each lot were tested. The % water content ranged from approximately 0.13% to 0.34% for these historical lots that were about 3-4 years old at the time of testing.

TABLE 12.7 Water Content in Formulation A and placebo compositions by Karl Fischer Titration % Water Content Formulation A Sample (Single Injection % Water Content ID ID per Vial) (Lot Average) A A-1 0.2503 0.2366 A-2 0.2229 B B-1 0.1516 0.1478 B-2 0.1439 C C-1 0.1561 0.1632 C-2 0.1702 D D-1 0.1311 0.1291 D-2 0.1271 E E-1 0.2192 0.2246 E-2 0.2299 F F-1 0.1504 0.1473 F-2 0.1442 G G-1 0.1451 0.1527 G-2 0.1602 H H-1 0.3296 0.3404 H-2 0.3512 I 1-1 0.1344 0.1286 1-2 0.1246 1-3 0.1264 1-4 0.1290 Placebo Placebo 0.1600 0.1618 Composition A A-1 Placebo 0.1635 A-2

Conclusions

To reduce or altogether eliminate the water content in Formulation A, the nitrogen purging pressure may be increased from 50 to 55 psi for not less than 5 minutes or until no more water is observed. The total amount of composition flushed through the filters prior to the vial filling step is recommended to remain as not less than 6 liters.

Example 13

The degree of coloration at 36 months, 25°/60% RH, for Formulation A, primary and supportive stability lots were compared to the water content that were determined at approximately 52 months after the date of manufacture, to see if a correlation exists between those two parameters. In addition, the degree of coloration at 36 months, 25°/60% RH, for a clinical lot of Formulation A was compared to its water content determined 34 months after manufacture.

Methods

Materials

-   -   1) Formulation A—Primary Stability Samples: PS-A, PS-B, PS-C and         PS-D (5 mL fill)     -   2) Formulation A—Supportive Stability Samples: SS-A, SS-B, SS-C         and SS-D (7.5 mL fill)     -   3) Formulation A—Clinical Samples: CS-A

Water Content Testing

Samples were tested according to USP <921>, Method 1c, using an EM Science Aquastar C3000 Coulometric Titrator. Due to the high viscosity of the formulation, the samples required dilution with methanol prior to introduction into the Coulometric Titrator. Approximately 0.5 g of Formulation A was accurately weighed into a 10 mL vial. An approximately equal amount of methanol was added and the weight accurately recorded. Each vial was then sealed and shaken vigorously for at least 30 seconds. Approximately 0.5 g of the sample/methanol mixture was delivered into the Coulometric Titrator by liquid injection. The syringe used to deliver the sample was weighed before and after injection to determine the amount assayed. Two vials per ICH stability lot were tested for water content, while four vials from Formulation A clinical samples CS-A were tested.

Degree of Coloration of Liquids

Samples were tested at the 36 months time point for Formulation A primary stability sample compositions, Formulation A supportive stability sample compositions and Formulation A clinical sample compositions. Color was determined on samples stored both upright and inverted. Formulation A clinical samples CS-A only had vials stored inverted.

Results

Table 13.1 summarizes the Degree of Coloration of Liquid results for the sustained release bupivacaine compositions at the 36 month time point, for samples stored at 25° C./60% RH in the inverted and upright orientations. The color data for samples CS-A at 36 months, stored only in the inverted orientation, is also included. The color results among the compositions were similar, with most of the results between 5× BY1 and 6× BY1. The color results for Formulation A indicate that the orientation of the vial during storage had no effect on color. Formulation A clinical samples CS-A was described as 6× BY1.

Included in Table 13.1 is the water content of the compositions of Formulation A, measured approximately 16 months after the color assessments were done at the 36 months stability time point. The water content ranged from approximately 0.13% to 0.34% for the compositions of Formulation A. In addition, the water content for Formulation A clinical samples CS-A was measured approximately 2 months before color was determined at the 36 months time point. Formulation A clinical samples CS-A had approximately 0.13% water.

FIG. 13 depicts the water content and coloration for each sample in Table 13.1. As seen in FIG. 13, at approximately 0.15% water, the color ranged from 4×-5× BY1 to 6× BY1; at approximately 0.23% water the color ranged from 5× BY1 to 6× BY1; and at approximately 0.34% water the color ranged from 5× BY to 5×-6× BY1.

Based on the results depicted in FIG. 13 and summarized in Table 13.1, the color of the Formulation A does not darken with an increase of water content in the approximate range of 0.13% to 0.34%.

TABLE 13.1 Water Content in Formulation A by Karl Fischer Titration and the Degree of Coloration of Liquids Data at 36 Months, at 25° C/60% RH, Stored Inverted and Upright Degree of Degree of Coloration at Coloration at 36 Months at 36 Months at 25° C./60% RH, 25° C./60% RH, % Water Stored Stored Content % Water Inverted, by PR-1562 Upright, by PR-1562 Fill (Single Content on Other Vials Not on Other Vials Not Composition Size Sample Injection (Lot Tested for Water Tested for Water ID (mL) ID per Vial) Average) Content Content PS-A 5 PS-A-1 0.2503 0.2366 Between 5x-6x BY1, 5x BY1, PS-A-2 0.2229 Between 5x-6x BY1 5x BY1 SS-A 7.5 SS-A-1 0.1516 0.1478 Between 4x-5x BY1, 5x BY1, SS-A-2 0.1439 Between 5x-6x BY1 5x BY1 PS-B 5 PS-B-1 0.1561 0.1632 5x BY1, 5x BY1, PS-B-2 0.1702 6x BY1 6x BY1 SS-B 7.5 SS-B-1 0.1311 0.1291 5x BY1, 5x BY1, SS-B-2 0.1271 Between 5x-6x BY1 Between 4x-5x BY1 PS-C 5 PS-C-1 0.2192 0.2246 Between 5x-6x BY1, 5x BY1, PS-C-2 0.2299 Between 5x-6x BY1 6x BY1 SS-C 7.5 SS-C-1 0.1504 0.1473 Between 5x-6x BY1, 5x BY1, SS-C-2 0.1442 Between 5x-6x BY1 Between 5x-6x BY1 PS-D 5 PS-D-1 0.1451 0.1527 Between 5x-6x BY1, Between 5x-6x BY1, PS-D-2 0.1602 Between 5x-6x BY1 Between 5x-6x BY1 SS-D 7.5 SS-D-1 0.3296 0.3404 Between 5x-6x BY1, 5x BY1, SS-D-2 0.3512 Between 5x-6x BY1 5x BY1 CS-A 7.5 CS-A-1 0.1344 0.1286 6x BY1, 6x BY1 Not stored upright CS-A-2 0.1246 CS-A-3 0.1264 CS-A-4 0.1290

Example 14

The effect of peroxide from sucrose acetate isobutyrate or benzyl alcohol on Formulation A and placebo compositions was evaluated. Formulation A in this study includes 12% w/w bupivacaine, 66% w/w sucrose acetate isobutyrate (SAIB), and 22% w/w benzyl alcohol, as described above. Placebo compositions were composed of 75% w/w sucrose acetate isobutyrate (SAIB), and 25% w/w benzyl alcohol. Bupivacaine N-oxide in the sustained release bupivacaine compositions can be formed by an oxidative reaction between bupivacaine and peroxides.

Methods

The peroxide content for several lots of sucrose acetate isobutyrate were determined by potentiometric titration involving iodometric titration. The bupivacaine N-oxide levels in samples of Formulation A were determined using HPLC with UV detection. Primary stability sample compositions, clinical samples, and the two optimization sample compositions of Formulation A were prepared at a scale of 150 L. Samples used for the heating study were prepared at a scale of 2.5 L. The heating study evaluated the effect of temperature during preparation.

Results

The levels of bupivacaine N-oxide in Formulation A on stability at 25° C./60% RH and the peroxide content in SAIB compositions used to prepare samples of Formulation A are listed in Table 14.1. The bupivacaine N-oxide data in Table 14.1 are for the longest available stability time points for each set of samples. These range from 3 months for the two optimization lots, up to 36 months for the four primary stability samples (each filled to 5 mL and 7.5 mL) of Formulation A and the clinical sample of Formulation A.

TABLE 14.1 Correlation of Peroxide Content of SAIB for preparing Samples of Formulation A and Bupivacaine N-Oxide Observed Time (Months) on Amount % Stability at Peroxide Bupivacaine 25° C./60% RH Composition Bupivacaine Content N-Oxide on for Data in Orientation ID Sample ID (ppm) Stability Column to the Left on Stability Bupivacaine PS-A 66 0.3 36 inverted Composition Bupivacaine SS-A 66 0.3 36 inverted Composition Bupivacaine PS-B 86 0.3 36 inverted Composition Bupivacaine SS-B 86 0.3 36 inverted Composition Bupivacaine PS-C 60 0.3 36 inverted Composition Bupivacaine SS-C 60 0.3 36 inverted Composition Bupivacaine PS-D 66 0.3 36 inverted Composition Bupivacaine SS-D 66 0.3 36 inverted Composition Clinical CS-A 236 1.6% of total Bupivacaine SAIB in Composition product lot 222 15.1% of total SAIB in product lot 198 29.6% of total SAIB in product lot 211 53.7% of total SAIB in product lot

Table 14.2 summarizes the result of peroxide content from a heating study that evaluated the effect of temperature during preparation.

TABLE 14.2 Peroxide Content of SAIB for preparing Samples of Formulation A and Bupivacaine N-Oxide in Optimization Lots and Heating Study Observed Time (Months) on Amount % Stability at Peroxide Bupivacaine 25° C./60% RH Composition Content N-Oxide on for Data in Orientation ID (ppm) Stability Column to the Left on Stability Heating Study HS-A 184 0.6 6 inverted Heating Study HS-B 184 0.6 6 inverted Optimization OL-A 19 BQL 3 inverted Lot - 1 Optimization OL-B 19 BQL 3 inverted Lot - 2

FIG. 14 illustrates a linear regression line fitted to the SAIB peroxide content data versus the bupivacaine N-oxide levels data. Based on the linear regression equation, it is estimated that the 1.0% specification limit for bupivacaine N-oxide corresponds to 296.4 ppm peroxide in SAIB. To ensure not exceeding the 1.0% limit for bupivacaine N-oxide, the target peroxide content can be adjusted to a value that corresponds to 0.8% bupivacaine N-oxide. This peroxide content value is calculated to be 232.5 ppm using the equation in FIG. 14.

To determine the fraction of bupivacaine N-oxide that may result from the peroxide impurities in benzyl alcohol, benzyl alcohol lots used in the preparation of the samples of Formulation A listed in Table 14.3 were examined Table 14.3 lists the benzyl alcohol compositions with their determined peroxide values (PV). All of the benzyl alcohol compositions had peroxide values of less than 0.5. The peroxide value can be converted to peroxide content, expressed as hydrogen peroxide, by multiplying PV by 17. This results in peroxide content data for all the benzyl alcohol lots as <8.5 ppm. Since the samples of Formulation A contain benzyl alcohol and SAIB in a 1:3 w/w ratio, the effective peroxide content of benzyl alcohol that would contribute to oxidizing bupivacaine to bupivacaine N-oxide is one third that of the peroxide content of SAIB. With this calculation, each lot of benzyl alcohol that was used in the samples of Formulation A listed in Table 14.3 effectively had <2.8 ppm (8.5 ppm divided by 3 equals 2.8 ppm) contribution to the formation of bupivacaine N-oxide. The maximum contribution to peroxide content from benzyl alcohol is 85 ppm divided by 3, or 28 ppm.

TABLE 14.3 Peroxide Content of Benzyl Alcohol used for preparing samples of Formulation A Effective Benzyl Benzyl Benzyl Alcohol Alcohol Alcohol Bupivacaine Peroxide Peroxide Peroxide Composition Composition Benzyl Alcohol Value (PV) Content Content ID No. ID from CofA (ppm) (ppm) Bupivacaine PS-A BA Composition 1 <0.5 <8.5 <2.8 Composition Bupivacaine SS-A BA Composition 1 <0.5 <8.5 <2.8 Composition Bupivacaine PS-B BA Composition 2 <0.5 <8.5 <2.8 Composition Bupivacaine SS-B BA Composition 2 <0.5 <8.5 <2.8 Composition Bupivacaine PS-C BA Composition 3 <0.5 <8.5 <2.8 Composition Bupivacaine SS-C BA Composition 3 <0.5 <8.5 <2.8 Composition Bupivacaine PS-D BA Composition 2 <0.5 <8.5 <2.8 Composition Bupivacaine SS-D BA Composition 2 <0.5 <8.5 <2.8 Composition Clinical CS-A BA Composition 4 <0.5 <8.5 <2.8 Bupivacaine Composition Heating Study HS-A BA Composition 5 <0.5 <8.5 <2.8 Heating Study HS-B BA Composition 5 <0.5 <8.5 <2.8 Optimization OL-A BA Composition 6 <0.5 <8.5 <2.8 Lot - 1 Optimization OL-B BA Composition 6 <0.5 <8.5 <2.8, <2.8 Lot - 2 and BA Composition 7

Example 15

The stability of various batches of Formulation A was studied. The results of these exemplary batches are summarized in Tables 15.1 and 15.2 and FIGS. 15-23. The stability of the samples of Formulation A in this study was assayed using HPLC with UV detection.

Samples of Formulation A (5 mL) were examined for photostability. Four different sample lots of Formulation A (11A-11C) were characterized and summarized in Tables 15.1 and 15.2. The photostability of each sample of Formulation A was studied under three different conditions: 1) light unprotected; 2) light protected using foil; and 3) light protected and packaged. The colors exhibited by each of the tested samples as well as the degree of coloration of the samples are summarized in Tables 15.1 and 15.2. In addition, Tables 15.1 and 15.2 summarize the label strength as well as presence of benzyl acetate and benzyl isobutyrate in the tested samples.

FIG. 15 depicts the label strength of 4 primary (5 mL) and 4 secondary (7.5 mL) lots of samples of Formulation A over a 36-month period. The label strength was measured for each sample at a temperature of 25° C. and 60% relative humidity.

FIG. 16 depicts the change in the presence of the N-oxide of bupivacaine (measure in % bupivacaine N-oxide) in 4 primary (5 mL) and 4 secondary (7.5 mL) lots of samples of Formulation A over a 36-month period. The amount of bupivacaine N-oxide in the samples was measured for each sample at a temperature of 25° C. and 60% relative humidity.

FIG. 17 depicts the presence of 2,6-dimethylaniline (measure in ppm) in 4 primary (5 mL) and 4 secondary (7.5 mL) lots of samples of Formulation A over an 18-month period (months 18-36). The amount of 2.6-dimethylaniline in the samples was measured for each sample stored at a temperature of 25° C. and 60% relative humidity. FIG. 18 depicts the presence of 2,6-dimethylaniline in samples of Formulation A stored for a 6-month period at 3 different temperatures (25° C., 30° C. and 40° C.) and 2 different relative humidities (60% RH, 75% RH).

FIG. 19 depicts the presence of benzyl acetate (measure in mg/mL) in 4 primary (5 mL) and 4 secondary (7.5 mL) lots of samples of Formulation A over a 36-month period. The amount of benzyl acetate in the samples was measured for each sample stored at a temperature of 25° C. and 60% relative humidity. FIG. 20 depicts the presence of benzyl acetate in samples of Formulation A stored for a 6-month period at 3 different temperatures (25° C., 30° C. and 40° C.) and 2 different relative humidities (60% RH, 75% RH).

FIG. 21 depicts the presence of benzyl isobutyrate (measure in mg/mL) in 4 primary (5 mL) and 4 secondary (7.5 mL) lots of samples of Formulation A over a 36-month period. The amount of benzyl isobutyrate in the samples was measured for each sample stored at a temperature of 25° C. and 60% relative humidity. FIG. 22 depicts the presence of benzyl isobutyrate in samples of Formulation A stored for a 6-month period at 3 different temperatures (25° C., 30° C. and 40° C.) and 2 different relative humidities (60% RH, 75% RH).

FIG. 23 depicts the change in the percent SAIB in 4 primary (5 mL) and 4 secondary (7.5 mL) lots of samples of Formulation A over a 36-month period. The change in the percent SAIB of samples of Formulation A was measured for each sample stored at a temperature of 25° C. and 60% relative humidity.

TABLE 15.1 Stability Results for Formulation A - Sample 1 - Photostability Study, 5 mL Acceptance Criteria Appearance Clear light yellow to amber Assay¹ Benzyl Benzyl solution; Degree of 93.0- Acetate ^(a) Isobutyrate ^(a) essentially free Coloration of 105.0% NMT NMT Lot Size of particulate Liquids label 20.0 10.0 Number (mL) Condition matter NMT 6x BY1 strength mg/mL mg/mL 11A 5 Light Pass³/Light BY4 (with 97.2 3.4 1.4 Storage - Yellow yellow tint), (97.1, (3.4, (1.4, Unprotected² BY4 (with 97.2) 3.4) 1.4) yellow tint) Light Pass/Yellow BY3, BY3 97.8 3.4 1.4 Storage - Brown (97.7, (3.4, (1.4, Protected, 97.9) 3.4) 1.4) Foil Light Pass/Yellow BY3, BY3 98.4 3.4 1.5 Storage - Brown (98.6, (3.4, (1.5, Protected, 98.2) 3.4) 1.4) Package 11B 5 Light Pass/Light BY4 (with 98.7 4.1 1.6 Storage - Yellow yellow tint), (98.7, (4.1, (1.6, Unprotected BY4 (with 98.7) 4.1) 1.6) yellow tint) Light Pass/Yellow BY3, BY3 99.9 4.1 1.7 Storage - Brown (100.0, (4.1, (1.7, Protected, 99.7) 4.0) 1.7) Foil Light Pass/Yellow BY3, BY3 99.7 4.1 1.7 Storage - Brown (99.5, (4.1, (1.6, Protected, 99.8) 4.1) 1.7) Package ¹Average (Individual) results reported ²Light Storage = Accelerated light storage condition ³Pass = clear, essentially free of particulate matter

TABLE 15.2 Stability Results for Formulation A - Sample 2 - Photostability Study, 5 mL Acceptance Criteria Appearance Clear light yellow to amber Assay¹ Benzyl Benzyl solution; Degree of 93.0- Acetate ^(a) Isobutyrate ^(a) essentially free Coloration of 105.0% NMT NMT Lot Size of particulate Liquids label 20.0 10.0 Number (mL) Condition matter NMT 6x BY1 strength mg/mL mg/mL 11C 5 Light Pass³/Light BY4 (with 97.2 3.4 1.4 Storage - Yellow yellow tint), (97.1, (3.4, (1.4, Unprotected² BY4 (with 97.2) 3.4) 1.4) yellow tint) Light Pass/Yellow BY3, BY3 97.8 3.4 1.4 Storage - Brown (97.7, (3.4, (1.4, Protected, 97.9) 3.4) 1.4) Foil Light Pass/Yellow BY3, BY3 98.4 3.4 1.5 Storage - Brown (98.6, (3.4, (1.5, Protected, 98.2) 3.4) 1.4) Package 11D 5 Light Pass/Light BY4 (with 98.7 4.1 1.6 Storage - Yellow yellow tint), (98.7, (4.1, (1.6, Unprotected BY4 (with 98.7) 4.1) 1.6) yellow tint) Light Pass/Yellow BY3, BY3 99.9 4.1 1.7 Storage - Brown (100.0, (4.1, (1.7, Protected, 99.7) 4.0) 1.7) Foil Light Pass/Yellow BY3, BY3 99.7 4.1 1.7 Storage - Brown (99.5, (4.1, (1.6, Protected, 99.8) 4.1) 1.7) Package ¹Average (Individual) results reported ²Light Storage = Accelerated light storage condition ³Pass = clear, essentially free of particulate matter

Example 16

Comparison of In Vitro Dissolution Profiles for Bupivacaine Formulations with Varying Amounts of SAIB and Solvent (N=3 or 4)

To compare dissolution profiles, formulations having 12% w/w bupivacaine but differing ratios of sucrose acetate isobutyrate (SAIB)/solvent were made and tested as described in the below Methods and Materials. Table 16.1 is a summary of the compositions of the formulations tested.

TABLE 16.1 Bupivacaine/SAIB/BA (target % w/w) composition of each formulation tested Compositions (target % w/w) Formulation Benzyl Visual Variant Bupivacaine Alcohol SAIB Appearance Control 12.0 22.0 66.0 solution −30% SAIB 12.0 41.8 46.2 solution −40% SAIB 12.0 48.4 39.6 solution −50% SAIB 12.0 55.0 33.0 solution −70% SAIB 12.0 68.2 19.8 solution −90% SAIB 12.0 81.4 6.6 solution

In vitro release of bupivacaine for the formulations shown in Table 16.1 was assessed according to the methods described in the below Methods and Materials. FIG. 24 shows the mean cumulative release of the control formulation (N=4), −30% SAIB formulation (N=3), −40% SAIB formulation (N=3), −50% SAIB formulation (N=4), −70% SAIB formulation (N=3), and −90% SAIB formulation (N=3).

FIG. 24 shows that the cumulative release profile of the control is similar to those of the −30%, −40%, and −50% SAIB formulations. The cumulative release profile of the control is faster than those of the −70% and −90% SAIB formulations. Using the average dissolution data from the control as a reference, the similarity factor f₂ and difference factor f₁ were calculated for the −30%, −40%, −50%, −70%, and −90% SAIB formulations. See below for an explanation of the f₁ and f₂ factors. As shown in Table 16.2, the −30%, −40%, and −50% SAIB formulations had f₁ and f₂ factors that would indicate that they are not different relative to the control.

TABLE 16.2 Difference (f₁) and Similarity (f₂) Factors of Formulations Relative to Control Compositions (target % w/w) Difference Similarity Formulation Benzyl Factor Factor Variant Bupivacaine Alcohol SAIB f₁ f₂ Control 12.0 22.0 66.0 NA NA −30% SAIB 12.0 41.8 46.2 4 82 −40% SAIB 12.0 48.4 39.6 7 68 −50% SAIB 12.0 55.0 33.0 8 62 −70% SAIB 12.0 68.2 19.8 18 45 −90% SAIB 12.0 81.4 6.6 29 36 Comparison of In Vitro Dissolution Profiles for Bupivacaine Formulations with Varying Amounts of SAIB and Solvent (N=12)

To compare dissolution profiles, formulations having 12% w/w bupivacaine but differing ratios of sucrose acetate isobutyrate (SAIB)/solvent were made and tested as described below. Table 16.3 is a summary of the compositions of the formulations tested.

TABLE 16.3 Bupivacaine/SAIB/BA (target % w/w) composition of each formulation tested Compositions (target % w/w) Formulation Benzyl Visual Variant Bupivacaine Alcohol SAIB Appearance Control 12.0 22.0 66.0 solution ±20% SAIB 12.0 8.8 79.2 suspension −20% SAIB 12.0 35.2 52.8 solution −70% SAIB 12.0 68.2 19.8 solution

In vitro release of bupivacaine for the formulations shown in Table 16.3 was assessed according to the methods described in the below Methods and Materials. FIG. 25 shows the mean cumulative release of the control formulation (N=12), +20% SAIB formulation (N=12), −20% SAIB formulation (N=12), and −70% SAIB formulation (N=12).

FIG. 25 shows that the release profile of the control is similar to those of the +20% and −20% SAIB formulations. The cumulative release profile of the control is faster than that of the −70% SAIB formulation. Using the average dissolution data from the control as a reference, the similarity factor f₂ and difference factor f₁ were calculated for the +20%, −20%, and −70% SAIB formulations. See below for an explanation of the f₁ and f₂ factors. As shown in Table 16.4, the +20% and −20% SAIB formulations had f₁ and f₂ factors that would indicate that they are not different relative to the control.

TABLE 16.4 Difference (f₁) and Similarity (f₂) Factors of Formulations Relative to Control Compositions (target % w/w) Difference Similarity Formulation Benzyl Factor Factor Variant Bupivacaine Alcohol SAIB f₁ f₂ Control 12.0 22.0 66.0 NA NA ±20% SAIB 12.0 8.8 79.2 3 84 −20% SAIB 12.0 35.2 52.8 3 86 −70% SAIB 12.0 68.2 19.8 18 44 Comparison of In Vitro Dissolution Profiles for Bupivacaine Formulations Made with Variable Heating

To compare dissolution profiles, a control formulation and a heat-stressed SAIB formulation were made and tested as described the below Methods and Materials. Both the control and heat-stressed SAIB formulations nominally consisted of 12% w/w bupivacaine, 22% w/w benzyl alcohol, and 66% w/w SAIB.

In vitro release of bupivacaine for the formulations described above was assessed according to the methods described below. FIG. 26 shows the mean cumulative release of the control formulation (N=12) and heat-stressed SAIB formulation (N=12).

Comparison of the heat-stressed SAIB formulation with the control in FIG. 26 shows that both formulations were similar from 1 to 18 hours. Starting at 24 hours, the release profile of the heat-stressed SAIB formulation levels off reaching about 66% drug released at 72 hours.

Methods and Materials

Cumulative Release of Bupivacaine In Vitro

The in vitro cumulative release of bupivacaine from formulations was determined as follows.

Materials

The bupivacaine formulations, other than the heat-stressed formulation, were prepared by dissolving appropriate amounts of bupivacaine in appropriate amounts of benzyl alcohol (BA), adding an appropriate amount of sucrose acetate isobutyrate (SAIB), and stirring not less than 45 minutes at about 35° C. For the heat-stressed SAIB formulation, the same process was followed except the SAIB was pre-heated in an oven at 225° C. for 4 hours before use. A portion of the pre-heated SAIB was tested and found to have 98% SAIB remaining.

Dissolution Testing

Dissolution was measured using a USP Apparatus II. Approximately 0.5 mL of each formulation was loaded via cannula and syringed into 900 mL±5 mL of 37±0.5° C. dissolution media (phosphate buffer at pH 7.4±0.05 with 0.03% sodium lauryl sulfate). The USP Apparatus II was set at 50 RPM, and samples were collected at 1, 4, 8, 12, 18, 24, 36, 48, and 72 hours. The number of replicates (N) per sample per time point varied as described above. The collected samples were assayed for bupivacaine content by HPLC.

Statistical Analysis

The dissolution profile comparisons were conducted using a difference factor (f₁) and a similarity factor (f₂) approach (FDA Guidance for Industry “Dissolution Testing of Immediate Release Solid Oral Dosage Forms” August 1997). The difference factor calculates the percent difference between two curves at each time point and is a measurement of the relative error between the two curves, as shown in Equation 1:

f ₁={[Σ_(t=1) ^(n) |R _(t) −T _(t)|]/[Σ_(t=1) ^(n) R _(t)]}×100}  (1)

In Equation 1, R_(t) and T_(t) represent the mean dissolution results obtained from the reference and test lots respectively, at each dissolution time point t, while n represents the number of dissolution time points.

The similarity factor (f₂) is a logarithmic reciprocal square root transformation of the sum of squared error and is a measurement of the similarity in the percent dissolution between the two curves, as shown in Equation 2.

f ₂=50×log{[1+(1/n)Σ_(t=1) ^(n)(R _(t) −T _(t))²]^(−0.5)×100}  (2)

The terms in Equation 2 are as defined in Equation 1. The value of f₂ can range from 0 to 100, with a larger f₂ indicating greater similarity between the reference and test article. A f₂ value of 50 corresponds to an average difference of 10% at each time point.

For two curves to be considered similar, the f₁ value should be close to 0, and the f₂ value should be close to 100. Generally, f₁ values of 0-15 and f₂ values of 50-100 ensure sameness or equivalence of two curves, and thus of the performance of the test and reference products.

Example 17

A randomized, parallel-group, double-blind, saline placebo-controlled and bupivacaine HCl active-controlled clinical trial evaluating the safety and efficacy of 5 mL of Formulation A in subjects undergoing elective outpatient laparoscopic cholecystectomy was conducted. In this study, Formulation A was prepared as described above and includes 3 components (sucrose acetate isobutyrate 66 wt %, benzyl alcohol 22.0 wt %, and bupivacaine base 12.0 wt %) that are administered together as a sterile solution.

Methods

The trial included: 1) a randomized, parallel-group, double-blind, placebo-controlled study (Part 1) and a randomized, parallel-group, double-blind, bupivacaine HCl active-controlled study (Part 2). The trial evaluated the efficacy and safety of Formulation A (bupivacaine, benzyl alcohol, sucrose acetate isobutyrate) as a delivery system in subjects undergoing elective outpatient laparoscopic cholecystectomy.

In Part 1, subjects were randomized in a nominal 1:1 ratio to receive 1 of 2 treatments, Formulation A or saline placebo. In Part 2, subjects were randomized in a 1:1 ratio to receive 1 of 2 treatments, Formulation A or bupivacaine HCl.

The study was conducted as 2 separate parts (Part 1 and Part 2). For part 1, 92 subjects were randomized and treated by instilling either 5 mL of Formulation A or saline placebo with a blunt-tipped applicator directly into the laparoscopic port incisions at the close of surgery. For part 2, subjects were randomized in a 1:1 ratio to receive 5 mL of Formulation A instilled with a blunt-tipped applicator directly into the laparoscopic port incisions or 15 mL (75 mg) bupivacaine HCl 0.5% infiltrated with a 22 gauge needle into the margins of the port incisions.

Subjects underwent surgery on Day 1, during which they were administered a single dose of Formulation A, placebo or bupivacaine HCl at the close of surgery while still anesthetized.

All subjects had access to adequate pain relief through the use of rescue medication. While in the post-anesthesia care unit (PACU), subjects were administered IV fentanyl 12.5-25 μg upon request for breakthrough pain. Upon discharge, subjects were provided with acetaminophen 500 mg tablets for mild-to-moderate pain and a prescription for oxycodone 5 mg immediate-release tablets for moderate-to-severe pain. Subjects self-administered these medications on an as-needed basis according to written dosing instructions provided by the site investigator or study staff.

Subjects were issued an electronic diary (LogPad) to record the specified data after surgery.

In part 1 of the study 92 patients in total were administered Formulation A or saline placebo. 45 patients were administered 5 mL of Formulation A and 47 patients received the placebo. For part 2 of the study, 296 patients were treated with Formulation A or active control, bupivacaine HCl. 148 patients were administered 5 mL of Formulation A and 148 patients received active control bupivacaine HCl.

Formulation a, Dose and Mode of Administration:

In Part 1 and Part 2, subjects randomized to the test product were administered 5 mL Formulation A (132 mg/mL bupivacaine base, 660 mg total) by direct instillation into the surgical incisions. The 5 mL of Formulation A was divided between the 4 ports according to a protocol-specified dosing schedule, to provide coverage of all surgical incisions. The fascia was closed, as required, prior to instillation of Formulation A. Formulation A was instilled into the incisions via a blunt-tipped syringe-tip applicator just prior to skin closure. After administration, the skin was closed in standard fashion with subcuticular sutures and cyanoacrylate skin adhesive or Steri-Strips™.

Reference Comparator, Dose and Mode of Administration:

Part 1:

In Part 1, subjects randomized to saline-placebo were administered sterile normal saline 5 mL (0.9% sodium chloride injection, USP) by direct instillation into the surgical incisions. The 5 mL of placebo was divided between the 4 ports according to a protocol-specified dosing schedule, to provide coverage of all surgical incisions. The fascia was closed, as required, prior to instillation of the placebo composition. The placebo composition was instilled into the incisions via a blunt-tipped syringe-tip applicator just prior to skin closure. After administration, the skin was closed in standard fashion with subcuticular sutures and cyanoacrylate skin adhesive or Steri-Strips™.

Part 2:

In Part 2, subjects randomized to active control were administered bupivacaine HCl 0.5% 15 mL (75 mg; without epinephrine) by infiltration into the margins of the surgical incisions with a 22 gauge needle. The 15 mL of bupivacaine HCl composition was divided between the 4 ports according to a protocol-specified dosing schedule, to provide coverage of all surgical incisions. The fascia was closed, as required, prior to administration of the bupivacaine HCl active control composition. After infiltration, the skin was closed in standard fashion with subcuticular sutures and cyanoacrylate skin adhesive or Steri-Strips™

Efficacy Analyses Primary

The primary efficacy endpoints for Part 1 and Part 2 were as follows:

Part 1: Pain intensity on movement measured at scheduled time points from 0 to 72 hours following test drug administration, adjusted for prior rescue medication use and analyzed by a mixed effect ANOVA model of repeated measures (MMRM).

Part 2: Pain intensity on movement measured at scheduled time points from 0 to 48 hours following test drug administration, adjusted for prior rescue medication use and analyzed by a mixed effect ANOVA model of repeated measures (MMRM).

Results

Efficacy Results:

Primary Endpoint

The primary efficacy endpoint was pain intensity on movement measured at scheduled time points from 0-72 hours (Part 1) and 0-48 hours (Part 2) following administration of test composition, adjusted for prior rescue medication use. For Part 1, the comparison was between Formulation A (Part 1 subjects only) and saline placebo, and for Part 2, the comparison was between Formulation A (Part 2 subjects only) and bupivacaine HCl. Results of the primary endpoint analysis are summarized in Table 17.1 below.

TABLE 17.1 Primary Outcomes by Study Part: Pain Intensity on Movement from 0 to 72 Hours Post-treatment (Part 1) and from 0 to 48 Hours Post-treatment (Part 2) Part 1 Part 2 Saline Bupivacaine Formulation A Placebo Formulation A HCl (N = 46) (N = 46) (N = 148) (N = 148) Pain intensity on movement 0 to 72 hours Mean (SE) 4.38 (0.091) 5.17 (0.107) 95% CI (4.21, 4.56) (4.96, 5.38) Pain intensity on movement 0 to 48 hours Mean (SE) 5.55 (0.065) 5.87 (0.059) 95% CI (5.42, 5.67) (5.76, 5.99) Formulation A versus comparator ^([1]) LS Mean Difference −0.785 (0.432) (SE) −0.371 (0.2412) 95% CI (−1.631, 0.062) (−0.844, 0.101) p-value 0.0692 0.1235 CI = confidence interval; SE = standard error; LS = least squares; WOCF = worst observation carried forward

Safety Results

There were no fatalities in this trial. Nine treated subjects (6 Formulation A and 3 bupivacaine HCl) experienced treatment-emergent serious adverse events (SAE), all of which were considered unrelated to study drug administration. Table 17.2 summarizes the safety data.

TABLE 17.2 Overall Summary of Treatment Emergent Adverse Events (Safety Population) Part 1 Part 2 Saline Bupivacaine Formulation A Placebo Formulation A HCl (N = 45 (N = 47) (N = 148) (N = 148) At Least One TEAE 43 (95.6%) 47 (100%) 148 (100%) 146 (98.6%) At Least One Spontaneously-reported 43 (95.6%) 45 (95.7%) 148 (100%) 138 (93.2%) TEAE At Least One LogPad-Solicited TEAE 36 (80.0%) 39 (83.0%) 134 (90.5%) 132 (89.2%) At Least One Serious TEAE 1 (2.2%) 0 (0.0%) 5 (3.4%) 3 (2.0%) At Least One TEAE Leading to Study 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (0.7%) Discontinuation Maximum Relationship to Study Drug Related 32 (71.1%) 26 (55.3%) 125 (84.5%) 104 (70.3%) Not Related 11 (24.4%) 21 (44.7%) 23 (15.5%) 42 (28.4%) Maximum Severity Mild 13 (28.9%) 22 (46.8%) 83 (56.1%) 92 (62.2%) Moderate 23 (51.1%) 25 (53.2%) 55 (37.2%) 49 (33.1%) Severe 7 (15.6%) 0 (0.0%) 10 (6.8%) 5 (3.4%) At Least One Severe and Related TEAE 5 (11.1%) 0 (0.0%) 0 (0.0%) 0 (0.0%) At Least One Serious and Related TEAE 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) Fatal TEAE 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%)

Example 18

A phase 3 international, multicenter, randomized, double-blind, parallel-group trial of 5 mL Formulation A (132 mg/mL, 660 mg bupivacaine) in patients undergoing a variety of general surgical procedures with various wound sizes was conducted.

Methods

The study was an international, multicenter, randomized, double-blind, parallel-group controlled trial evaluating the safety, efficacy, effectiveness, and pharmacokinetics (PK) of 5 mL of Formulation A in patients undergoing a variety of general surgical procedures with various wound sizes. All surgical procedures were elective, non-urgent, and indicated for the conditions identified below.

Randomization was stratified by surgical procedure (cohort) and by clinical site. The cohorts were as follows:

Cohort 1: Laparotomy. Approximately 50 patients were randomized to receive either 5 mL of Formulation A or Bupivacaine HCl 30 mL 0.5% solution in a 3:2 ratio, respectively. This cohort included patients undergoing open laparotomy for resection of liver, small bowel, stomach, spleen, gall bladder, or colon.

Cohort 2: Laparoscopic cholecystectomy. Approximately 50 patients were randomized to receive either 5 mL of Formulation A or Bupivacaine HCl 30 mL 0.5% solution in a 3:2 ratio, respectively.

Cohort 3: Laparoscopically-assisted colectomy. Approximately 204 patients were randomized to receive either 5 mL of Formulation A or vehicle-Placebo 5 mL in a 3:2 ratio, respectively. This cohort included patients undergoing laparoscopically-assisted colectomy without planned formation or closure of stoma for colon cancer, diverticulitis, or polyps. A pneumoperitoneal and an intracorporeal approach was used to explore the abdomen, mobilize the colon, identify critical structures, and ligate the vascular pedicle for left-sided and sigmoid colectomies.

Active Control, Dose and Mode of Administration:

In the active comparator treatment groups (Cohorts 1 and 2); 30 mL of Bupivacaine HCl 0.5% solution (5 mg/mL, 150 mg bupivacaine) was administered by infiltration with a hypodermic needle into the peri-incisional tissues.

Formulation A, Dose and Mode of Administration:

For the Formulation A (132 mg/mL, 660 mg bupivacaine as described above) and vehicle placebo treatment groups, 5 mL of each composition was drawn up and administered using a NORM-JECT® 5-mL Luer Lock syringe connected to a Tunneltip™ irrigation catheter with a Luer Lock fitting. The supplied Tunneltip irrigation catheter was flexible, 15 cm long, 2 mm in diameter, with smooth rounded tip and graduated centimeter markings for wound length measurement and control of instillation. To account for the dead space in the catheter, sites were instructed to draw 5.5 mL of investigational product in the syringe with the provided 16 gauge needle. Sites were instructed to purge excess air and investigational product from the syringe and catheter once connected to ensure administration of 5 mL of each composition. The syringes, needles, and catheters were supplied sterile and individually packaged.

For laparoscopic portals, each composition was administered directly into the open port incision through an irrigation catheter and/or by the syringe tip. The port incision was then closed with a suture after dosing. For linear incisions, after closure of the peritoneum and securing hemostasis in the subcutaneous space, the irrigation catheter was placed into the wound and the cutaneous layer was closed over the catheter with subcuticular stitches. The syringe containing each composition was then attached to the catheter and test drug was gradually injected while slowly withdrawing the catheter. In this way, each composition (e.g., Formulation A or vehicle control) was evenly distributed along the length of the incision with minimal leakage of the drug. A final stitch was used to close the space where the catheter was withdrawn. The volume delivered per centimeter of wound length was calculated based on incision length measured using the centimeter marking on the irrigation catheter.

In Cohort 1, the entire 5 mL dose of Formulation A was evenly distributed within the laparotomy incision. In Cohort 2, the larger port incisions received a larger volume of Formulation A than did the smaller port incisions. In Cohort 3, there was generally a 5-10 cm linear incision for exteriorizing the colon for resection and anastomosis (the hand port). Approximately 80-90% of Formulation A was instilled into the hand port using the irrigation catheter method. The remaining 10-20% of test drug was directly instilled into the laparoscopic port incisions.

To avoid seepage of the product from the wound, instillation was performed after a tight closure of the skin with subcuticular stitches (no staples) and Steri-Strips. No drains were placed in the area of investigational product placement.

Results

Efficacy

Two co-primary endpoints were chosen to evaluate the efficacy of Formulation A compared to control: 1) time normalized AUC of pain intensity on movement over 0-72 hours and 2) total amount of rescue opioids taken over 0-72 hours expressed as IV morphine equivalents. The primary pain endpoint was defined as the time normalized AUC of pain on movement over 0-72 hours. The AUC was calculated by the trapezoid method using both scheduled pain intensity scores on movement (recorded electronically on a LogPad device) as well as pain scores recorded each time rescue opioids were administered for postoperative pain relief.

Table 18.1 summarizes the primary endpoint AUC of 0-72 hours as well as the secondary endpoint AUC of 0-48 hours. In addition, the AUC by day was presented to assess the duration of treatment effect.

TABLE 18.1 Pain Intensity on Movement AUCs by Period (Includes both Log Pad and Opioid Pain Scores) LS Mean 95% CI LS Mean for the for the p-value Period Treatment N (SE) 95% CI difference difference (ANCOVA) Cohort 1 (Laparotomy) AUC 0-72 hours Formulation A (5 mL) 26 4.9 (0.43) (4.0, 5.7) −0.89 (−2.11, 0.33) 0.1473 Bupivacaine HCl 17 5.8 (0.51) (4.7, 6.8) AUC 0-48 hours Formulation A (5 mL) 26 5.2 (0.42) (4.4, 6.1) −0.77 (−1.96, 0.42) 0.1953 Bupivacaine HCl 17 6.0 (0.49) (5.0, 7.0) AUC 0-24 hours Formulation A (5 mL) 26 5.7 (0.42) (4.9, 6.6) −0.54 (−1.71, 0.62) 0.3507 Bupivacaine HCl 17 6.3 (0.48) (5.3, 7.2) AUC 24-48 hours Formulation A (5 mL) 26 4.7 (0.47) (3.8, 5.7) −1.01 (−2.36, 0.33) 0.1332 Bupivacaine HCl 17 5.7 (0.56) (4.6, 6.9) AUC 48-72 hours Formulation A (5 mL) 26 4.1 (0.50) (3.1, 5.1) −1.13 (−2.56, 0.30) 0.1168 Bupivacaine HCl 17 5.3 (0.60) (4.0, 6.5) Cohort 2 (Laparoscopic Cholecystectomy) AUC 0-72 hours Formulation A (5 mL) 30 2.8 (0.38) (2.0, 3.6) −1.06 (−2.16, 0.05) 0.0601 Bupivacaine HCl 20 3.9 (0.45) (3.0, 4.8) AUC 0-48 hours Formulation A (5 mL) 30 3.2 (0.39) (2.5, 4.0) −1.19  (−2.30, −0.07) 0.0371 Bupivacaine HCl 20 4.4 (0.45) (3.5, 5.3) AUC 0-24 hours Formulation A (5 mL) 30 3.7 (0.40) (2.9, 4.5) −1.17  (−2.33, −0.01) 0.0488 Bupivacaine HCl 20 4.8 (0.47) (3.9, 5.8) AUC 24-48 hours Formulation A (5 mL) 30 2.8 (0.16) (2.5, 3.1) −1.20  (−1.84, −0.56) 0.0002 Bupivacaine HCl 20 4.0 (0.22) (3.5, 4.4) AUC 48-72 hours Formulation A (5 mL) 30 2.0 (0.44) (1.1, 2.9) −0.79 (−2.07, 0.48) 0.2158 Bupivacaine HCl 20 2.8 (0.52) (1.7, 3.8) Cohort 3 (Laparoscopically Assisted Colectomy) AUC 0-72 hours Formulation A (5 mL) 126 4.8 (0.19) (4.4, 5.2) −0.34 (−0.80, 0.12) 0.1483 Vehicle placebo 77 5.1 (0.23) (4.7, 5.6) AUC 0-48 hours Formulation A (5 mL) 126 5.2 (0.19) (4.8, 5.5) −0.30 (−0.74, 0.14) 0.1829 Vehicle placebo 77 5.5 (0.22) (5.0, 5.9) AUC 0-24 hours Formulation A (5 mL) 126 5.4 (0.19) (5.0, 5.8) −0.33 (−0.79, 0.12) 0.1489 Vehicle placebo 77 5.8 (0.23) (5.3, 6.2) AUC 24-48 hours Formulation A (5 mL) 126 4.9 (0.22) (4.4, 5.3) −0.31 (−0.83, 0.20) 0.2275 Vehicle placebo 77 5.2 (0.25) (4.7, 5.7) AUC 48-72 hours Formulation A (5 mL) 126 4.0 (0.24) (3.6, 4.5) −0.40 (−0.97, 0.18) 0.1784 Vehicle placebo 77 4.4 (0.29) (3.9, 5.0)

FIGS. 27 to 29 present line graphs of the mean pain intensity on movement±standard error of the mean (SEM) versus the scheduled time of pain assessment for each cohort. It can be seen from these Figures that the initial pain intensity of Cohorts 1 and 3 was similar, as both cohorts involved colectomy or other major abdominal surgery, and ranged from pain scores of 7 to 8, which was considered severe pain. Cohort 2 had a lower initial pain score, ranging from 5 to 6, which was considered moderate to severe pain. In all 3 cohorts, the mean pain intensity on movement decreased by 2 to 3 units over a 3-day postoperative period, with Cohorts 1 and 3 reaching moderate pain levels whereas Cohort 2 declined to mild pain levels. Cohorts 1 and 2 showed an early separation of the treatment groups that was maintained over the entire 72-hour period. Cohort 3 had little separation of the treatment groups, which was consistent with the relatively small therapeutic effect observed with the primary endpoint.

Pre-Specified Sensitivity Analyses of Pain Intensity on Movement

A pre-specified sensitivity analysis was a repeated measures mixed model and is summarized in Table 18.2.

TABLE 18.2 Repeated Measures Pain Intensity on Movement 0-72 Hours Based on LogPad Scores Only (ITT Population) LS Mean 95% CI LS Mean for the for the p-value Period Treatment N (SE) 95% CI difference difference (ANCOVA) Cohort 1 (Laparotomy) All Timepoints Formulation A (5 mL) 26 4.9 (0.30) (4.2, 5.5) −1.0 (−1.83, −0.17) 0.0202 0-72 hr Bupivacaine HCl 17 5.9 (0.35) (5.1, 6.6) Cohort 2 (Laparoscopic Cholecystectomy) All Timepoints Formulation A (5 mL) 30 2.7 (0.27) (2.2, 3.2) −0.9 (−1.66, −0.13) 0.0235 0-72 hr Bupivacaine HCl 20 3.6 (0.32) (3.0, 4.2) Cohort 3 (Laparoscopically Assisted Colectomy) All Timepoints Formulation A (5 mL) 126 4.7 (0.15) (4.4, 5.0) −0.6 (−0.93, −0.21) 0.0020 0-72 hr Vehicle-Placebo 77 5.3 (0.18) (4.9, 5.6) ANCOVA = analysis of covariance, CI = confidence interval, ITT = intent-to-treat, LS = least squares, SE = standard error

Use of Rescue Medication

The second co-primary endpoint was the mean total amount of opioids administered over 0-72 hours, expressed as IV morphine equivalents in milligrams using standard conversion factors to convert different opioids to morphine equivalents.

Table 18.3 summarizes the results with respect to the second co-primary endpoint.

TABLE 18.3 Total Morphine-equivalent Opioid Medication Use by Period and Cohort (ITT Population) 95% CI P-value Treatment Median Median for the (Wilcoxon Period Group N (Q1, Q3) Difference Difference Rank-Sum) Cohort 1 (Laparotomy) MEDD 0-72 Formulation A 26 87.0 (30.0, 157.0) −1.0  (−54.5, 52.0) 0.9901 hours (mg) (5 mL) Bupivacaine 17 63.0 (34.0, 152.0) HCl Cohort 2 (Laparoscopic Cholecystectomy) MEDD 0-72 Formulation A 30 17.0 (8.0, 26.0) −5.0 (−14.0, 3.4) 0.2010 hours (mg) (5 mL) Bupivacaine 20 22.5 (12.5, 34.5) HCl Cohort 3 (Laparoscopically Assisted Colectomy MEDD 0-72 Formulation A 126 52.0 (24.0, 86.6) −3.0 (−15.0, 8.0) 0.5897 hours (mg) (5 mL) Vehicle- 77 62.0 (24.0, 86.0) Placebo a. CI = confidence interval, MEDD = mean equivalent daily dose of morphine, ITT = intent-to-treat, Q = quartile

Pharmacokinetics

Plasma PK samples were analyzed for determination of total bupivacaine concentration only and none of the samples were analyzed for determination of free drug concentration. Table 18.4 summarizes the PK parameters for all three cohorts. The graphs of plasma bupivacaine concentration vs. time after treatment are presented in FIGS. 30 to 32.

TABLE 18.4 Plasma Pharmacokinetic Parameters by Cohort - mean [range] Cohort 1 Cohort 2 Formulation Bupivacaine Bupivacaine Cohort 3 PK A HCl Formulation A HCl Formulation A Parameter (N = 30) (N = 18) (N = 30) (N = 20) (N = 129) C_(max) (ng/mL) 956 [133-1870] 251 [19-551] 752 [357-1850] 371 [101-1170] 850 [92-2850] T_(max) (hr) Median 48 [2-73] 16 [1-48] 24 [1-49] 1 [1-24] 47 [1-74] AUC₍₀₋₇₂₎ (ng*hr/mL) 40755 [5113-79464] 8465 [495-26306] 29466 [11095-68124] 6772 [1777-11985] 39437 [3613-110222] AUC_((0-last)) (ng*hr/mL) 41942 [635-96625] 7784 [465-26364] 30997 [11100-68108] 6623 [1771-11868] 39602 [1626-136309]

Safety Evaluation

Patient safety was carefully monitored throughout the trial with traditional assessments of AEs, vital signs, routine laboratory testing, and Holter monitoring (i.e., continuous recording of electrocardiogram) for 3 days after dosing. Special attention was given to cardiovascular and neurological AE, as bupivacaine toxic effects are manifest in those two body systems. In addition, special assessments were done to monitor surgical wound condition and healing over the 30 days of the trial.

Table 18.5 summarizes the overall adverse experience by cohort.

TABLE 18.5 Overall Summary of Treatment-Emergent Adverse Events, Serious Adverse Events, and Deaths (Safety Population) Cohort 1 Cohort 2 Cohort 3 Bupivacaine Bupivacaine Vehicle Formulation A HCl Formulation A HCl Formulation A Placebo (N = 30) (N = 18) (N = 30) (N = 20) (N = 129) (N = 78) At Least One TEAE 30 (100%) 17 (94%) 28 (93%) 20 (100%) 126 (98%) 75 (96%) At Least One 4 (13%) 7 (39%) 2 (7%) 2 (10%) 19 (15%) 6 (8%) Cardiovascular TEAE At Least One 6 (20%) 4 (22%) 17 (57%) 10 (50%) 23 (18%) 29 (37%) Neurological TEAE At Least One Wound 4 (13%) 2 (11%) 1 (3%) 1 (5%) 12 (9%) 2 (3%) Infection TEAE At Least One Non- 27 (90%) 17 (94%) 27 (90%) 19 (95%) 124 (96%) 74 (95%) Opioid TEAE At Least One 9 (30%) 4 (22%) 0 1 (5%) 16 (12%) 9 (12%) Serious TEAE At Least One 1 (3%) 0 0 1 (5%) 0 0 TEAE Leading to Study Discontinuation Maximum Relationship to Study Drug Related 12 (40%) 4 (22%) 17 (57%) 10 (50%) 79 (61%) 47 (60%) Not Related 18 (60%) 13 (72%) 11 (37%) 10 (50%) 47 (36%) 28 (36%) Maximum Severity Mild 5 (17%) 2 (11%) 4 (13%) 2 (10%) 54 (42%) 29 (37%) Moderate 16 (53%) 11 (61%) 16 (53%) 13 (65%) 51 (40%) 32 (41%) Severe 9 (30%) 4 (22%) 8 (27%) 5 (25%) 21 (16%) 14 (18%) At Least One 1 (3%) 0 2 (7%) 1 (5%) 0 2 (3%) Severe and Related TEAE At Least One 1 (3%) 0 0 0 0 1 (1%) Serious and Related TEAE Deaths 0 0 0 0 1 (<1%) 0

There were no consistent treatment-related effects on vital signs. Changes in serum chemistry and hematological parameters were those expected after major surgery, with few consistent differences between treatment groups. Cardiac safety was carefully studied using Holter monitoring for 72 hours post-dose, starting about one hour before surgery. In addition, baseline 24-hour ambulatory Holter monitoring was done after the screening visit. Careful analysis of the Holter data and correlation of the QTc interval with bupivacaine plasma concentration did not reveal any evidence for QTc prolongation by Formulation A. The Holter recordings were further analyzed for arrhythmias and no instances of ventricular tachycardia were detected in any of the recordings.

It is concluded that Formulation A was well tolerated when instilled into a variety of abdominal surgical wounds at a dose of 5 mL (660 mg) and that there was no evidence of systemic bupivacaine toxicity as assessed by AEs, laboratory testing, and intensive Holter monitoring. With the exception of an increased incidence of post-operative bruising, tissue tolerability of Formulation A compares well to bupivacaine HCl.

Example 19

A double-blind, placebo-controlled pharmacodynamic and pharmacokinetic dose response study was conducted to Formulation A instilled directly into the wound in patients undergoing open inguinal hernia repair. In this study, Formulation A was prepared as described above and includes 3 components (sucrose acetate isobutyrate 66 wt %, benzyl alcohol 22.0 wt %, and bupivacaine base 12.0 wt %) that are administered together as a sterile solution.

Objectives

To examine the dose response efficacy, pharmacokinetics, safety and tolerability of Formulation A instilled into the wound in patients undergoing open inguinal hernia repair.

Methods

Study Design

This was a Phase II, multicenter, randomized, double-blind, placebo-controlled, parallel-group, dose-finding study.

Participants

Patients were male or female, 18 to 65 years of age, and were planned to undergo elective open unilateral tension-free Lichtenstein-type inguinal hernia repair under general anesthesia. Patients were in good health prior to study participation, based on a medical history, physical examination, 12-lead electrocardiogram (ECG), and laboratory tests. All patients had to have a systolic blood pressure (BP) of ≤160 mmHg and a diastolic BP of ≤95 mmHg, use a medically acceptable method of contraception throughout the study period and for 1 week after completion of the study, refrain from strenuous activities throughout the study period and avoid modifications to prescribed exercise levels throughout the study period, and read, understand, communicate, and voluntarily sign the approved informed consent form prior to the performance of any study specific procedures.

Patients were excluded if they were pregnant or lactating; had previous abdominal surgery with scar tissue that would limit the patients' ability to participate; had clinically significant hepatic, gastrointestinal, renal, hematologic, urologic, neurologic, respiratory, endocrine, or cardiovascular system abnormalities, psychiatric disorders, or acute infection unrelated to the disease under study; had connective tissue disorders (systemic lupus erythematosus, scleroderma, mixed connective tissue disease); or had a known sensitivity to bupivacaine, or benzyl alcohol (BA). Patients with known or suspected alcohol abuse within the 6 months prior to study enrollment or illicit drug use, current or regular use of analgesic medication for other indication(s), current or regular use of triptyline or imipramine antidepressants, or monoamine oxidase inhibitors; or use of any prescription drugs or over the counter medication that started within 7 days before treatment and throughout the study (except for birth control medications) that might interfere with the conduct or interpretation of the study results were excluded, as were patients who participated in another clinical study concurrent or within 30 days of enrollment and those who were unwilling or unable to comply with the study procedures.

Interventions

The inguinal hernia operative procedure was performed according to standard local practice under general anesthesia. Patients were randomized to receive 2.5 mL or 5.0 mL of Formulation A (12.0 wt %, 132 mg/mL bupivacaine), or 2.5 mL or 5.0 mL of Placebo. All treatments were administered during wound closure, and were instilled gradually throughout the inguinal canal and the abdominal wall layers to cover all raw surfaces of the wound, filling the subaponeurotic and subcutaneous spaces.

Outcome Measures

Pain intensity at rest and on movement was evaluated using a numerical rating scale ([NRS] 0=no pain; 10=worst pain possible) on Day 0 at 1, 2, 3, 4, 6, 8, 10, and 12 hours following medication administration, on Days 1 to 4 at 8:00 am, 12:00 pm, 4:00 μm, and 8:00 pm, on Day 5 at 8:00 am, and prior to dosing with any rescue medication from Day 0 to 14. The modified Brief Pain Inventory was completed once daily at 12:00 pm on Days 1 to 5. Postoperative analgesia was prescribed according to a suggested guideline, and rescue medication use, concomitant medications, and adverse events (AEs) were recorded throughout the study. Time from surgery to patient mobilization, typical bowel movement pattern, last bowel movement prior to surgery, and the number of bowel movements after treatment were measured. Blood samples were collected for pharmacokinetic analysis for a minimum of 32 patients on Day 0 at −5 min, and 1, 2, 3, 4, 8, and 12 hours, and on Days 1 to 4, and 7 at approximately the same time of day that the treatment was administered on Day 0. Surgical site healing and local tissue conditions evaluated at follow up visits on Days 1 to 4, 7, and 14, where appropriate. Specific safety evaluations performed as part of the modified Brief Pain Inventory included nausea/vomiting, drowsiness, itching, constipation, dizziness, tinnitus, dysgeusia, and paresthesia. Vital signs were recorded at screening, on Day 0 prior to and immediately following treatment administration, and hourly thereafter up to the 8-hour evaluation time point or discharge (whichever occurred first), as well as on Days 1 to 3, and 14. Physical examinations and safety laboratory assays were performed at screening and on Day 14. A 12-lead ECG was performed at screening and when clinically indicated to evaluate and record all clinically significant abnormalities (e.g., bradycardia episodes); 2 study centers performed continuous ECG monitoring for 24 hours as soon as practical after the surgical procedure and, if clinically indicated, a 12-lead ECG was performed. Patients returned to clinic for 3- and 6-month follow-up visits for physical examinations, evaluations of surgical site healing and local tissue conditions, and collections of adverse event and concomitant medication data.

Sample Size

Approximately 144 patients were randomized to the study in order to yield 120 total evaluable patients (60 patients per cohort with a 3:1 randomization in favor of active treatment within each cohort). A relative treatment effect of 0.67 (between Placebo 5.0 mL and Formulation A 5.0 mL groups) was detected based on the mean pain intensity on movement area under the curve (AUC) over the period of 1 to 72 hours with 80% power and a 5% significance level.

Randomization

Prior to surgery, eligible patients were randomly assigned to receive one of the following 4 treatments: Formulation A 5.0 mL (660 mg of bupivacaine), Formulation A 2.5 mL (330 mg of bupivacaine), Placebo 5.0 mL, or Placebo 2.5 mL. Each randomized patient received a randomization number comprising the cohort membership (Cohort 1 or Cohort 2; 60 randomized patients per cohort as defined below) and a treatment group (3:1 randomization in favor of active treatment). Placebo groups (2.5 mL and 5.0 mL) were pooled a priori to potentially increase the statistical analysis power.

The 2 cohorts were as follows:

-   -   Cohort 1: Patients were randomized to receive either 2.5 mL of         Formulation A or 2.5 mL of Placebo;     -   Cohort 2: Patients were randomized to receive either 5.0 mL of         Formulation A or 5.0 mL of Placebo.         This randomization scheme resulted in 3 distinct treatment         groups, as follows:     -   Treatment Group 1: Formulation A 2.5 mL (330 mg of bupivacaine);     -   Treatment Group 2: Formulation A 5.0 mL (660 mg of bupivacaine);     -   Treatment Group 3: Placebo 2.5 mL or 5.0 mL, as randomly         assigned.

Number of Patients

Number of Patients Planned

Up to 144 patients were to be enrolled to obtain 120 evaluable patients.

Patients Analyzed

There were 135 patients enrolled and 124 were randomized as follows: Formulation A 2.5 mL, N=45; Formulation A 5.0 mL, N=47; placebo, N=32. Four patients discontinued the study (Formulation A 2.5 mL, N=3; placebo, N=1); thus, 120 patients completed the study and comprised the efficacy evaluable population: Formulation A 2.5 mL, N=42; Formulation A 5.0 mL, N=47; placebo, N=31. The safety/per protocol (PP) population included 123 patients (Formulation A 2.5 mL, N=44; Formulation A 5.0 mL, N=47; placebo, N=32), and the intention-to-treat (ITT) population included 122 patients (Formulation A 2.5 mL, N=43; Formulation A 5.0 mL, N=47; placebo, N=32).

Diagnosis and Main Criteria for Inclusion

Male and female patients, in good general health, 18 to 65 years of age, who were planned to undergo elective open unilateral tension-free Lichtenstein-type inguinal hernia repair under general anesthesia.

Duration of Treatment

Treatment was administered at one time on the day of surgery (Day 0).

Criteria for Evaluation

Efficacy

There were 2 coprimary efficacy endpoints: the mean pain intensity on movement normalized AUC over the time period 1 to 72 hours post-surgery, and the proportion of patients who received opioid rescue medication during the study. Primary null hypotheses were no differences between treatment groups in terms of mean pain intensity on movement normalized AUC or opioid rescue medication. Secondary efficacy endpoints included the following: mean pain intensity normalized AUC over the time period of 1 to 48 hours post-surgery, post-surgery time-to-opioid medication use, overall treatment satisfaction, mean total opioid dose converted into morphine equivalence for analgesia rescue during the study, and mean function activities (Days 1 through 5). Exploratory analyses included calculations of normalized mean pain intensity AUCs (on movement and at rest) for 1 to 24 hours, 1 to 96 hours, and 1 to 120 hours (using the last observation carried forward [LOCF] method).

Pharmacokinetics

Plasma samples were collected in a subset of patients at one selected study center for pharmacokinetic assessments.

Safety

Safety outcomes included AEs, surgical site healing and local tissue condition evaluations, ECGs, laboratory tests, vital signs, and physical examinations.

Statistical Methods

Primary Endpoints

The mean pain intensity AUC was compared between treatment groups using an Analysis of Variance (ANOVA) model that included treatment group and study site as factors. A Dunnett test was used to carry out the pairwise comparison of the placebo group (aggregated) and the two Formulation A doses. The proportion of patients who received opioid rescue medication was analyzed using a Cochran-Mantel-Haenszel (CMH) test.

Secondary Endpoints

Time-to-opioid use was analyzed using a log-rank test. The Cox proportional hazards model was also used to estimate the hazard ratio and its 95% confidence interval (CI).

Dose Response

The quantification of the efficacy dose response was examined by testing the monotonic relationship between the 3 treatment groups (placebo [aggregated], and Formulation A 2.5 mL and 5.0 mL) as a function of pain intensity. A step-down approach was used to address multiplicity of comparisons.

Results

Efficacy Results

Efficacy results for the primary pain on movement endpoint are summarized in Table 19.1. The 5 mL dose of Formulation A was highly significant compared to placebo, whereas the 2.5 mL Formulation A did not reach significance, but pain intensity AUC was lower than placebo. A reduction in mean pain intensity at rest normalized AUC from 1 to 72 hours was observed in favor of both active doses of Formulation A against placebo, albeit not statistically significant.

TABLE 19.1 Normalized AUC of Pain Intensity on Movement (1-72 hours), ITT Formulation A 2.5 mL Formulation A 5.0 mL Placebo Mean (SEM) 3.11 (0.25) 2.47 (0.19) 3.60 (0.30) p-value vs Placebo 0.157 0.0033

The mean pain intensity on movement normalized AUC from 1 to 48 hours was improved with Formulation A versus placebo, with a statistically significant difference (p=0.0007) observed between 5.0 mL of Formulation A (mean [SEM], 2.52 [0.19]) and placebo (3.86 [0.31]), and a trend toward significance with 2.5 mL of Formulation A (3.18 [0.24]) versus placebo (p=0.0654). In addition, the mean pain intensity at rest normalized AUC from 1 to 48 hours trended toward a significant improvement with 5.0 mL of Formulation A versus placebo (mean [SEM], 1.54 [0.13] vs. 2.18 [0.23]; p=0.0515), but the difference between 2.5 mL of Formulation A (2.15 [0.22]) and placebo was not statistically significant.

Opioid rescue analgesia after surgery was used in approximately 53.2% ( 25/47; 95% CI: 38.1%, 67.9%) of patients in the 5.0 mL Formulation A group, 72.1% ( 31/43; 95% CI: 56.3%, 84.7%) of patients in the 2.5 mL Formulation A group, and 71.9% ( 23/32; 95% CI: 53.3%, 86.3%) of patients in the placebo group; the difference between 5.0 mL of Formulation A and placebo approached statistical significance in the ITT population (p=0.0909).

The median time-to-first opioid use was greatest with 5.0 mL of Formulation A (131.8 hours; 95% CI: 31.9, not defined), followed by 2.5 mL of Formulation A (10.8 hours; 95% CI: 1.1, 52.7), and then placebo (2.7 hours; 95% CI: 1.1, 25.3); the difference between 5.0 mL of Formulation A and placebo was statistically significant (p=0.0174).

The IV morphine equivalent dose of rescue medication taken from 0-72 hours after treatment is summarized in Table 19.2. Rescue medication use was significantly lower for Formulation A 5 mL compared to placebo, whereas the 2.5 mL dose of formulation did not reach statistical significance.

TABLE 19.2 IV Morphine Equivalent Use 0-72 Hours (ITT Population) Formulation A Formulation A 2.5 ml 5 ml Placebo N 43   47 32 Mean (SE) 11.2 (2.01) 7.9 (1.60) 23.5 (6.85) Median 5.0 2.5 12.5 Formulation A 5 ml vs Placebo Median difference [1] −7.5 95% CI [1] (0.0, 15.0) P-value [2] 0.0085 Formulation A 2.5 ml vs Median difference [1] −5.0 95% CI [1] (0.0, 10.0) P-value [2]   0.1333 [1] Hodges-Lehmann estimates for median difference [2] [Wilcoxon rank-sum test

Most patients (>90%) in each treatment group were satisfied or very satisfied, and mean scores for each function activity improved from Day 1 to 5 in all 3 treatment groups.

A statistically significant improvement was observed with 5.0 mL of Formulation A versus placebo in the mean pain intensity on movement normalized AUC from 1 hour to last (mean [SEM], 2.27 [0.18] vs. 3.03 [0.25], respectively; p=0.0211), but not with Formulation A 2.5 mL (2.96 [0.25]) versus placebo. Similarly, normalized mean AUCs of pain intensity on movement from 1 to 24, 1 to 96, and 1 to 120 hours was lowest with 5.0 mL of Formulation A (mean [SEM], 2.21 [0.21], 2.37 [0.18], and 2.30 [0.18], respectively), followed by 2.5 mL of Formulation A (2.85 [0.25], 3.04 [0.26], and 2.93 [0.26], respectively), and last placebo (4.05 [0.31], 3.31 [0.29], and 3.03 [0.28], respectively).

Pharmacokinetic Results

Plasma concentrations of bupivacaine increased proportionally with the dose administered and there was no burst of drug delivery observed upon administration of Formulation A. The observed mean (SEM) pharmacokinetic parameters of bupivacaine are listed in Table 19.3

TABLE 19.3 2.5 mL 5.0 mL Pharmacokinetic Parameters Formulation A Formulation A C_(max) (ng/mL), mean (SEM) 466.79 (60.48) 866.57 (114.02) T_(max) (hr), median (range) 12.0 (2.9-24.10) 23.95 (4.0-24.10) AUC_(last) (ng*hr/mL), mean (SEM) 18327.8 (2597.7) 40822.9 (5428.5) AUC_(inf) (ng*hr/mL), mean (SEM) 18542.8 (2636.6) 41461.4 (5404.3)

Safety Results

Safety results reported here refer to the safety population. The most common AEs (incidence of >10% in at least 1 treatment group) in the safety population (N=123) included somnolence, constipation, dizziness, pruritus, bradycardia, headache, postprocedural hemorrhage, postoperative wound complication, nausea, and dysgeusia. Adverse events from the modified Brief Pain Inventory (i.e., nausea/vomiting, drowsiness, itching, constipation, dizziness, ringing ears, metallic taste, and numbness or tingling of the toes or fingers) were reported in each treatment group. The incidence of all AEs probably or possibly related to treatment was 18.2% ( 8/44) in the 2.5 mL Formulation A group, 27.7% ( 13/47) in the 5.0 mL Formulation A group, and 28.1% ( 9/32) in the placebo group, and all were mild or moderate in severity.

Two safety analyses were performed: the original analysis imputed missing severity data as mild, and an ad-hoc analysis imputed missing severity data as severe. In both analyses, most AEs (>95% for original analysis, >70% for ad-hoc analysis) were mild or moderate in severity; 2 patients in each Formulation A group and no patients in the placebo group in the original analysis and 21 patients treated with Formulation A and 10 placebo-treated patients in the ad-hoc analysis experienced or had imputed a severe adverse event. Serious adverse events were reported in 6.8% ( 3/44), 4.3% ( 2/47), and 3.1% ( 1/32) of Formulation A 2.5-mL-, Formulation A 5.0-mL-, and placebo-treated patients, respectively; one event (vasovagal syncope) was considered possibly related to Formulation A treatment. Serious adverse events included acute coronary syndrome, vasovagal syncope, syncope, and postoperative wound complication. There were no deaths or other significant adverse events.

Nervous system adverse events were reported in 29 (66%), 25 (53%), and 23 (72%) Formulation A 2.5-mL-, Formulation A 5.0-mL-, and placebo-treated patients, respectively. Cardiac adverse events were experienced by 10 (23%), 15 (32%), and 7 (22%) patients treated with 2.5 mL of Formulation A, 5.0 mL of Formulation A, and placebo, respectively. There were 5 vasovagal syncopal episodes during recovery from general anesthesia among patients from all dose groups, including placebo. Cardiovascular causes of syncopes were ruled out.

Clinically significant laboratory abnormalities were infrequent and consisted of 1 positive glucose urine test at screening in the 2.5 mL Formulation A group and 1 high creatine kinase blood level at Day 14 in the placebo group. Heart rate (HR), BP, respiratory rate, temperature, and physical examination (except gastrointestinal hernia for repair) findings were similar from screening to Day 14 in all treatment groups. The surgical site healed as expected and local tissue conditions were as expected/normal in 95% of patients in each treatment group at all time points evaluated.

On ECG, Formulation A did not result in any clinically relevant changes in HR, PR, QRS, and QT interval corrected for HR durations. The QTcF result in the regular set of 12-lead ECGs showed a mean change from baseline placebo corrected +2 ms in the 2.5 mL Formulation A dose group and −8 ms in the 5.0 mL Formulation A dose group; changes which would not indicate any signal that Formulation A affected cardiac depolarization or repolarization. However, in the telemetry set of ECGs, the mean change in QTcF duration for 2.5 mL and 5.0 mL of Formulation A from baseline to 12 hours was +15 and +9 ms, respectively, and from baseline to 24 hours was +8 and −11 ms, respectively. These data showed a non-dose related increase in QTcF duration, likely due to lack of power, concomitant general anesthesia, and large spontaneous variability in QTc durations rather than a direct effect of Formulation A.

During the 6-month follow-up period, there were fewer AEs in the 5.0-mL Formulation A group (35.7%) compared with the placebo group (42.3%) or the 2.5-mL Formulation A group (58.3%). Most AEs were mild or moderate in severity. Serious AEs were reported at a rate of 11.1% in the 2.5-mL Formulation A group and 7.7% in the placebo group; no serious AEs were reported in the 5.0-mL Formulation A group. Postoperative wound complication was the only AE reported in >10% of patients, occurring in 7 (19.4%) of patients in the 2.5 mL Formulation A group and 3 (11.5%) of patients in the placebo group. Surgical site healing and local tissue conditions were as expected/normal in all patients at 6 months.

Conclusions

5.0 mL of Formulation A (660 mg bupivacaine) instilled directly into the wound was safe and effective in the management of pain in patients who underwent elective, open, unilateral, tension-free, inguinal hernia repair. 2.5 mL of Formulation A (330 mg bupivacaine) was not demonstrated to be sufficiently efficacious for pain management in inguinal hernia repair. 5.0 mL of Formulation A (660 mg) significantly improved mean pain intensity on movement normalized AUC compared with Placebo post-surgery for 48 and 72 hours. Patients treated with 5.0 mL of Formulation A (660 mg) required significantly less opioid rescue medication post-surgery compared with Placebo for 48 and 72 hours. Over the study period, 5.0 mL of Formulation A (660 mg) significantly prolonged the time to first opioid use compared with Placebo.

Efficacy endpoints in the 2.5 mL Formulation A (330 mg) group were not statistically significantly different from Placebo. However, a trend toward a significant difference versus Placebo was observed with mean pain intensity on movement normalized AUC from 1 to 48 hours and MEDD taken on Day 2. Patient satisfaction with overall pain treatment was observed in each treatment group and persisted throughout the duration of the study. Functional activity improved over time in all treatment groups. Pharmacokinetics of bupivacaine is observed to be dose proportional, with no drug release burst observed after administration of Formulation A.

Most AEs were mild or moderate in severity, and no deaths or other significant AEs occurred. During the 6-month follow-up period, serious AEs were reported at a similar incidence in patients treated with 2.5 mL of Formulation A (330 mg) and placebo, while none were reported in patients treated with 5.0 mL of Formulation A (660 mg). The active monitoring of cardiovascular toxicities suggests that no causal association was present between the single episodic exposure to Formulation A and cardiac events. Constipation, nausea, pruritus, tinnitus, somnolence, dizziness, headache, dysgeusia, and paresthesia were reported less frequently with 5.0 mL of Formulation A (660 mg) compared with placebo; however, postprocedural hemorrhage, postoperative wound complication, and bradycardia were reported more frequently with 5.0 mL of Formulation A (660 mg) compared with placebo.

The reduction in opioid rescue dose associated with 5.0 mL of Formulation A (660 mg) reduced the incidence of opioid-related AEs, including dizziness, nausea, and vomiting, and significantly reduced the incidence of constipation compared with placebo. Vital sign or physical examination changes over time were minimal Abnormal or unexpected surgical site healing or tissue evaluation, or clinically significant laboratory abnormalities was observed infrequently and incidences were similar between treatment groups. On ECG, Formulation A did not demonstrate any clinically relevant changes in HR, PR, QRS, or QTc durations. However, QTcF prolongation was observed, which was not dose-related and was likely due to a small sample size, concomitant general anesthesia, and large spontaneous variability in QTc durations. This study did not demonstrate clear and consistent ECG effects for either the lower (2.5 mL [330 mg]) or higher (5.0 mL [660 mg]) dose of Formulation A, suggesting that the higher dose does not expose patients to a greater risk of untoward cardiovascular effects.

Example 20

A patient-blinded, Phase II study was conducted to examine the pharmacokinetics (PK), safety, tolerability and efficacy of Formulation A instilled directly into the wound in patients undergoing elective open inguinal hernia repair. Operative procedures were performed under general anesthesia. In this study, Formulation A was prepared as described above and includes 3 components (sucrose acetate isobutyrate 66 wt %, benzyl alcohol 22.0 wt %, and bupivacaine base 12.0 wt %) that are administered together as a sterile solution. The aim of using the formulation is to provide prolonged local analgesia by slowly releasing bupivacaine over a period of several days.

Objectives

Primary objective— To examine the pharmacokinetics of a sustained release bupivacaine composition (i.e., Formulation A containing bupivacaine, benzyl alcohol, sucrose acetate isobutyrate as described above) instilled directly into the wound in patients undergoing elective open inguinal hernia repair.

Secondary objective—To examine the safety, efficacy and tolerability of Formulation A instilled directly into the wound in patients undergoing elective open inguinal hernia repair.

Methods

The studies was a pilot, patient-blinded, Phase II study to assess the pharmacokinetics, safety, tolerability and efficacy of Formulation A as a delivery system in open inguinal hernia repair patients. The study investigated instillation of Formulation A directly into the wound, with patients being enrolled into two treatment groups:

Treatment Group 1—During wound closure 2.5 mL of Formulation A was placed topically, in approximately equal volumes, into the superior, medial and inferior subaponeurotic spaces. After closure of the external oblique aponeurosis (and prior to skin closure) a further 2.5 mL of Formulation A was placed topically along the length of the sutured external oblique aponeurosis. The total delivered volume of Formulation A instilled into the wound was 5.0 mL.

Treatment Group 2—After closure of the external oblique aponeurosis (and prior to skin closure) 5.0 mL of Formulation A was placed topically along the length of the sutured external oblique aponeurosis. The total delivered volume of Formulation A instilled into the wound was 5.0 mL.

Number of patients: Patients planned— Up to 12 patients, with six per treatment group to achieve five evaluable patients per group; Patients Entered— 12 patients, with six per treatment group; Patients Completed— 12 patients, with six per treatment group.

Diagnosis and main criteria for inclusion of patient into study: The study population included male and female patients undergoing open repair of inguinal hernia under general anaesthesia.

Duration of Treatment

The study period lasted up to 21 days.

Criteria for Evaluation:

Efficacy: Daily pain intensity (numerical rating scale), daily opioid rescue analgesia and total daily analgesia. A modified brief pain inventory was used to assess daily pain control, worst pain, least pain, analysis of function, treatment satisfaction and individual pain intensity over time.

Safety: Adverse effects (AEs), wound healing and local tissue conditions, laboratory tests, physical examination and vital signs. The modified brief pain inventory also recorded certain safety evaluations including: nausea, vomiting, drowsiness, itching, constipation, dizziness, tinnitus, dysgeusia, parasthesia and the number of bowel movements following injection of study drug.

Pharmacokinetic: Non-compartmental PK analysis was performed on all patient data from whom PK blood samples were collected.

Statistical Methods:

The aim was for five evaluable patients to complete treatment in each group was used as the sample size calculation for this study.

Plasma bupivacaine concentration was summarized at each timepoint and WinNonLin was used to assess the data. The parameters of maximum plasma concentration (Cmax), time taken to reach Cmax (Tmax) and area under the curve (AUC), using the linear trapezoid rule, were summarized by treatment group and compared using a linear general method.

A plot of mean pain intensity score at pre-determined time points was used to assess both treatment groups simultaneously. Modified brief pain inventory data were summarized by treatment group, with pain control, worst pain and least pain summarized using an AUC. All pain assessment data were summarized by treatment group.

All opioid containing drugs were coded into morphine equivalents and the total morphine equivalent daily dose was calculated for each day. The average number of rescue analgesic tablets taken per day for Days 0-5, 6-14 and overall (Days 0-14) were calculated and summarized by treatment group. The proportion of patients who required no rescue analgesia during Days 0-5 was summarized by treatment group.

The overall incidence (number and percentage) of treatment emergent AEs and serious adverse events (SAEs) were summarized by treatment group. The incidence of AEs was also assessed in terms of maximum severity and relationship to study medication, for each MedDRA system organ class and preferred term. The proportion of patients reporting each common safety event recorded by the modified brief pain inventory was summarized by treatment group. Surgical site healing and local tissue condition data were listed and summarized by treatment group.

Vital signs data, changes from baseline and the number and proportion of patients with abnormal findings in each body system were summarized by treatment group at each visit. Data on typical bowel function were summarized and the number of bowel functions in each 24-hour period was summarized by treatment group. Concomitant medications taken were summarized by treatment group using ATC and WHO drug codes.

Laboratory data were listed, compared with sex-specific normal ranges and any changes from screening to the end of the study were calculated. The observed data and changes from screening were summarized by treatment group. Shift tables of hematology and biochemistry parameters between abnormally low/normal/abnormally high values from baseline to the end of treatment were produced by treatment group. The proportion of patients with abnormal values considered clinically significant was compared between treatment groups.

Results

Efficacy Results

In Treatment Group 1 where Formulation A was instilled into the subaponeurotic space and along the external oblique aponeurosis, the mean pain intensity scores at rest remained at a similar level over Days 0-1 and began to fall on Day 2. In Treatment Group 2 where Formulation A was instilled along the external oblique aponeurosis alone there was a slight increase in mean pain intensity scores from Day 0 to Day 1, with a subsequent reduction in pain levels on Days 2-3. Overall the mean pain intensity scores for Days 2-5 were consistently higher in Treatment Group 2 patients than in Treatment Group 1 patients and the pain intensity AUCs were also higher for patients in Treatment Group 2. (Table 20.1)

TABLE 20.1 Pain Intensity Scores at Rest (ITT Population) Subaponeurotic Spaces + Oblique Aponeurosis Oblique Aponeurosis Alone (Group 1) (N = 6) (Group 2) (N = 6) Time Mean ± SEM Median (95% CI) Mean ± SEM Median (95% CI) Day 0 4 hours 1.2 ± 0.65 0.5 (0.0, 4.0) 0.8 ± 0.40 0.5 (0.0, 2.0) 6 hours 0.8 ± 0.65 0.0 (0.0, 4.0) 0.5 ± 0.22 0.5 (0.0, 1.0) 8 hours 0.8 ± 0.65 0.0 (0.0, 4.0) 0.7 ± 0.33 0.5 (0.0, 2.0) 10 hours 0.8 ± 0.65 0.0 (0.0, 4.0) 1.5 ± 0.22 1.5 (1.0, 2.0) 12 hours 0.7 ± 0.49 0.0 (0.0, 3.0) 1.5 ± 0.22 1.5 (1.0, 2.0) Day 1 08:00 hours 0.5 ± 0.34 0.0 (0.0, 2.0) 2.3 ± 0.61 2.0 (1.0, 4.0) 12:00 hours 0.8 ± 0.40 0.5 (0.0, 2.0) 1.2 ± 0.48 1.0 (0.0, 3.0) 16:00 hours 1.3 ± 0.49 1.5 (0.0, 3.0) 1.5 ± 0.67 1.0 (0.0, 4.0) 20:00 hours 1.3 ± 0.49 1.5 (0.0, 3.0) 1.3 ± 0.76 1.0 (0.0, 5.0) Day 2 08:00 hours 0.8 ± 0.40 0.5 (0.0, 2.0) 1.2 ± 0.60 1.0 (0.0, 4.0) 12:00 hours 0.8 ± 0.31 1.0 (0.0, 2.0) 1.3 ± 0.61 1.0 (0.0, 4.0) 16:00 hours 0.2 ± 0.17 0.0 (0.0, 1.0) 1.2 ± 0.60 1.0 (0.0, 4.0) 20:00 hours 0.5 ± 0.34 0.0 (0.0, 2.0) 1.0 ± 0.60 0.5 (0.0, 4.0) Day 3 08:00 hours 0.2 ± 0.17 0.0 (0.0, 1.0) 0.8 ± 0.65 0.0 (0.0, 4.0) 12:00 hours 0.2 ± 0.17 0.0 (0.0, 1.0) 1.0 ± 0.63 0.5 (0.0, 4.0) 16:00 hours 0.3 ± 0.21 0.0 (0.0, 1.0) 0.8 ± 0.65 0.0 (0.0, 4.0) 20:00 hours 0.2 ± 0.17 0.0 (0.0, 1.0) 0.8 ± 0.65 0.0 (0.0, 4.0) Day 4 08:00 hours 0.2 ± 0.17 0.0 (0.0, 1.0) 1.0 ± 0.82 0.0 (0.0, 5.0) 12:00 hours 0.3 ± 0.33 0.0 (0.0, 2.0) 1.2 ± 0.79 0.5 (0.0, 5.0) 16:00 hours 0.2 ± 0.17 0.0 (0.0, 1.0) 1.0 ± 0.82 0.0 (0.0, 5.0) 20:00 hours 0.3 ± 0.21 0.0 (0.0, 1.0) 1.0 ± 0.82 0.0 (0.0, 5.0) Day 5 08:00 hours 0.2 ± 0.17 0.0 (0.0, 1.0) 0.8 ± 0.65 0.0 (0.0, 4.0) 12:00 hours 0.3 ± 0.21 0.0 (0.0, 1.0) 0.8 ± 0.65 0.0 (0.0, 4.0) AUC 0-120 hours 68.4 ± 36.86  31.0 (3.0, 240.2) 140.3 ± 67.88   61.4 (29.3, 462.8) SEM = standard error of mean; CI = confidence interval

A similar pattern was seen for pain intensity scores on movement. Most patients experienced good, very good or excellent pain control from Formulation A instillation into the wound, with only two patients in Treatment Group 2 experiencing fair pain control. No notable differences between treatment groups were seen when comparing pain control AUC values. The worst pain scores were higher on Day 1 in Treatment Group 2 but by Day 2 there were no notable differences between the treatment groups. The impact of post-surgical pain on ability to walk, social interactions, stay asleep and to cough was higher in Treatment Group 2 on Day 1, but by Day 2 was comparable between the two groups for most parameters. Most patients were satisfied or very satisfied with Formulation A treatment, with only two patients in Treatment Group 2 (i.e., where Formulation A was instilled along the external oblique aponeurosis alone) being fairly dissatisfied or only fairly satisfied with treatment. No differences between the two groups were seen for the other efficacy parameters evaluated.

More patients in Treatment Group 2 where Formulation A was instilled along the external oblique aponeurosis alone required rescue analgesia between Days 0-5 compared to patients in Treatment Group 1 where Formulation A was instilled into the subaponeurotic space as well as along the external oblique aponeurosis. However, patients in Treatment Group 2 only required rescue analgesia over Days 0-5, whereas one patient in Treatment Group 1 required rescue analgesia during Days 6-14.

TABLE 20.2 Total Daily Dose of Rescue Analgesia (tablets, ITT Population) Subaponeurotic Spaces + Oblique Oblique Aponeurosis Alone Aponeurosis (Group 1) (N = 6) (Group 2) (N = 6) Time Mean ± SEM Median (95% CI) Mean ± SEM Median (95% CI) Days 0-5 2.0 ± 1.63 0.0 (0.00, 10.00) 3.0 ± 1.24 3.0 (0.00, 8.00) Days 6-14 0.3 ± 0.33 0.0 (0.00, 2.00)  0.0 ± 0.00 0.0 (0.00, 0.00) Overall 2.3 ± 1.96 0.0 (0.00, 12.00) 3.0 ± 1.24 3.0 (0.00, 8.00)

Opioid analgesia used during the study was converted into intravenous morphine equivalent daily doses (MEDD) unit and the resulting supplemental opioid analgesia usage is summarized the table below. During the first 24 hours post-surgery, patients in Treatment Group 2 required more opioid therapy than patients in Treatment Group 1. However, after this 24-hour period, none of the patients in Treatment Group 2 required additional opioid analgesia, whereas some patients in Treatment Group 1 required opioid analgesia throughout Days 1-5.

TABLE 20.3 Summary of Opioid Analgesia Usage (MEDD, ITT Population) Subaponeurotic Spaces + Oblique Oblique Aponeurosis Alone Aponeurosis (Group 1) (N = 6) (Group 2) (N = 6) Time Mean ± SEM Median Range Mean ± SEM Median Range  1-24 hours 0.83 ± 0.833 0.00 0.0-5.0 2.50 ± 5.500 0.00 0.0-15.0  24-48 hours 1.67 ± 1.667 0.00 0.0-10.0 0.00 ± 0.000 0.00 0.0-0.0  48-72 hours 1.67 ± 1.054 0.00 0.0-5.0 0.00 ± 0.000 0.00 0.0-0.0  72-96 hours 0.00 ± 0.000 0.00 0.0-0.0 0.00 ± 0.000 0.00 0.0-0.0 96-120 hours 0.83 ± 0.833 0.00 0.0-5.0 0.00 ± 0.000 0.00 0.0-0.0 Days 1-5 1.00 ± 0.816 0.00 0.0-5.0 0.50 ± 0.500 0.00 0.0-3.0

Safety Results

The incidence of AEs was comparable between treatment groups. The only AEs reported in more than one patient per treatment group were post-procedural hemorrhage (three of six patients) and nausea (two of six patients). Nausea was experienced across both treatment groups on the day following surgery, whereas post-procedural hemorrhage was only experienced by patients in Treatment Group 1. Drowsiness and constipation were reported by individual patients within the first two days of the study. All AEs were mild (three of six patients in Treatment Group 2) or moderate (four of six patients in Treatment Group 1) in severity and none were considered related to the study treatment.

There were no deaths or withdrawals during the study. Only one patient experienced a severe adverse effect (SAE), comprising recurrence of inguinal hernia in a patient in Treatment Group 1. The SAE was not considered related to the study treatment and resolved over the course of the study.

The administration of Formulation A directly into the wound at a dose of 5.0 mL did not raise safety concerns over clinical laboratory, vital signs or physical examination parameters. In addition, the use of Formulation A did not appear to compromise wound healing, though abnormal local tissue conditions were recorded for three of the 12 patients. Administration of Formulation A to the subaponeurotic space and along the external oblique aponeurosis appeared to be associated with a slightly faster return to normal bowel function.

Pharmacokinetic Results

Quantifiable plasma bupivacaine concentrations were observed within 1-4 hours of Formulation A administration, which increased gradually to maximum concentrations around 12-24 hours in both the treatment groups. Sustained levels (between 100-400 ng/mL) were generally maintained for a period of 48-72 hours and then the concentrations started to decline in mono-exponential order.

In this study, the two treatment groups were different with respect to the method of drug administration, but the total volume of drug administered was 5.0 mL for both the groups. Overall pharmacokinetic parameters of bupivacaine between the two groups were similar, with somewhat higher variability in Group 2 (entire amount as wound infiltrate).

After correcting for the actual dose administered and normalizing to 1 mL dose, the plasma bupivacaine concentration seemed almost superimposable.

Conclusions

The pharmacokinetics of bupivacaine were similar between the two groups evaluated in this study. This study showed that Formulation A, instilled into either the subaponeurotic space and along the external oblique aponeurosis (Treatment Group 1) or instilled along the external oblique aponeurosis alone (Treatment Group 2), at a dose of 5.0 mL was well tolerated and not result in any clinically significant AEs. Instillation of Formulation A into the subaponeurotic space and along the external oblique aponeurosis (Treatment Group 1) showed better efficacy, particularly on Day 1, in terms of pain intensity scores, as well as the amount of time pain interfered with the ability to walk, social interactions, ability to stay awake and to cough. The patient's assessment of their overall pain control and satisfaction with treatment was higher when Formulation A was instilled into the subaponeurotic space and along the external oblique aponeurosis (Treatment Group 1) compared to along the external oblique aponeurosis alone (Treatment Group 2). Instillation of Formulation A into the subaponeurotic space and along the external oblique aponeurosis (Treatment Group 1) was associated with a reduced requirement for supplemental rescue and opioid analgesia in the first few days post-surgery.

Example 21

A randomized, double-blind, placebo-controlled study was conducted to examine the efficacy, tolerability and safety of Formulation A administered subcutaneously or into the subaponeurotic space in subjects undergoing elective open inguinal hernia repair. In this study, Formulation A and placebo was prepared as described above and is summarized below:

Composition: Formulation A - Sustained Release Bupivacaine Composition Active ingredient: Bupivacaine base Inactive ingredients: Sucrose acetate isobutyrate, benzyl alcohol Strength: 132 mg/mL, 660 mg bupivacaine

Composition Placebo Active ingredient: Not applicable Inactive ingredients: Sucrose acetate isobytyrate benzyl alcohol

Objectives

Primary objective— The primary objective was to determine the efficacy of Formulation A administered subcutaneously or into the subaponeurotic space in subjects undergoing elective open inguinal hernia repair.

Secondary objective—The secondary objectives were to determine the safety and tolerability of Formulation A administered subcutaneously or into the subaponeurotic space in subjects undergoing elective open inguinal hernia repair.

Since the mode of administration was different between Cohort 1 and Cohort 2, the study objectives were defined specifically for each cohort.

Methods

This was a randomized, double-blind, placebo-controlled, Phase 2 study to examine the efficacy of Formulation A instilled throughout the subaponeurotic and subcutaneous spaces, administered by injection into the subaponeurotic space, or administered subcutaneously in subjects undergoing elective open inguinal hernia repair and to assess the safety and tolerability of Formulation A as a delivery system.

The study was conducted in 2 separate and sequential cohorts (Cohort 1 and Cohort 2, summarized below). Approximately equal numbers of subjects were to be enrolled, in sequence, to each cohort. The study duration was up to 21 days that included screening, admission to clinic and surgery (Day 0), postoperative evaluations, discharge from clinic, and follow-up through Day 14.

The subjects were evaluated on Days 1, 2, 4, and 5 by telephone and returned to the clinic on Days 3 and 14 (follow-up). Subjects recorded pain intensity (PI), concomitant medications, adverse events (AEs), and rescue analgesia on diary cards from Days 0 through 5. Subjects also recorded AEs and concomitant medications through Day 14.

Cohort 1

Immediately prior to surgery, the first 45 subjects were randomly assigned in a 1:1:1 ratio to receive 1 of the following treatments:

Treatment Group 1: Prior to wound closure, 5.0 mL of Placebo was injected into the superior, medial, and inferior subaponeurotic spaces. After wound closure, Formulation A was administered as 2 trailing subcutaneous injections along each side of the incision line (suggested incision total length to be 4 to 6 cm). The total delivered volume of Formulation A was 5.0 mL.

Treatment Group 2: Prior to wound closure, 5.0 mL of Formulation A (12.0 wt %, 132 mg/mL bupivacaine was injected into the superior, medial, and inferior subaponeurotic spaces. After wound closure, Placebo was administered as 2 trailing subcutaneous injections along each side of the incision line (suggested incision total length to be 4 to 6 cm). The total delivered volume of Placebo was 5.0 mL.

Treatment Group 3: Prior to wound closure, 5.0 mL of Placebo was injected into the superior, medial, and inferior subaponeurotic spaces. After wound closure, Placebo was administered as 2 trailing subcutaneous injections along each side of the incision line (suggested incision total length to be 4 to 6 cm). The total subcutaneously delivered volume of Placebo was 5.0 mL. The total delivered volume of Placebo was 10.0 mL.

Cohort 2

Immediately prior to surgery, the second group of 45 subjects was randomly assigned in a 1:1 enrollment ratio to receive 1 of the following treatments:

Treatment Group 4: During the wound closure, 5.0 mL of Placebo was instilled gradually throughout the inguinal canal and the abdominal wall layers to cover all raw surfaces of the wound, filling up subaponeurotic and subcutaneous spaces.

Treatment Group 5: During the wound closure, 5.0 mL of Formulation A was instilled gradually throughout the inguinal canal and the abdominal wall layers to cover all raw surfaces of the wound, filling up subaponeurotic and subcutaneous spaces (7.5 mL specified for Cohort 2a comprising Treatment 5a).

Number of Subjects: The planned enrollment was 90 subjects in order to ensure 72 evaluable subjects who planned to undergo ambulatory open repair of inguinal hernia. The 90 subjects were to be divided evenly into 45 subjects in each cohort.

The final goal was for at least 72 evaluable subjects to complete the study (36 subjects in each cohort, 12 subjects in each treatment group of Cohort 1 and 18 in each treatment group of Cohort 2).

A total of 45 subjects were enrolled in Cohort 1; 13 to Treatment 1, 18 to Treatment 2, and 14 to Treatment 3. All 45 subjects completed Cohort 1. A total of 44 subjects were enrolled in Cohort 2; 21 to Treatment 4, 1 to Treatment 5a, and 22 to Treatment 5. Forty-one subjects completed Cohort 2; 1 subject in Treatment 4 and 2 subjects in Treatment 5 were lost to follow-up.

Diagnosis and main criteria for inclusion of patient into study: The study population included male and female subjects who were planning to undergo ambulatory open repair of inguinal hernia requiring an incision of 4 to 6 cm in length, were in good health, and were above 18 years of age.

Test product, dose and mode of administration

Cohort 1

Treatment 1: 10.0-mL vials of Formulation A (12.0 wt %) were used to fill 5.0-mL syringes for a 5.0-mL subcutaneous injection.

Treatment 2: 10.0-mL vials of Formulation A (12.0 wt %) were used to fill 5.0-mL syringes for injection of 5.0 mL into the superior, medial, and inferior subaponeurotic spaces.

Cohort 2

Treatment 5a: 10.0-mL vials of Formulation A (12.0 wt %) were used to fill 10.0-mL syringes to instill 7.5 mL into subaponeurotic and subcutaneous spaces.

Treatment 5: 10.0-mL vials of Formulation A (12.0 wt %) were used to fill 10.0-mL syringes to instill 5.0 mL into subaponeurotic and subcutaneous spaces.

Reference therapy, dose and mode of administration

Cohort 1

Treatment 1: 10.0-mL vials of Placebo were used to draw 5.0-mL syringes for injection of 5.0 mL into the superior, medial, and inferior subaponeurotic spaces.

Treatment 2: 10.0-mL vials of Placebo were used to draw 5.0-mL syringes for a 5.0-mL subcutaneous injection.

Treatment 3: 10.0-mL vials of Placebo were used to draw 5.0-mL syringes for a 5.0-mL subcutaneous injection and an injection of 5.0 mL into the superior, medial, and inferior subaponeurotic spaces.

Cohort 2

Treatment 4: 10.0-mL vials of Placebo (12.0 wt %) were used to draw 10.0-mL syringes to instill 5.0 mL into subaponeurotic and subcutaneous spaces.

Duration of Treatment

Subjects received a single dose of Formulation A. The study duration was up to 21 days comprising screening, admission to clinic and surgery (Day 0), postoperative evaluations, discharge from clinic, and follow-up through Day 14.

Criteria for Evaluation:

Efficacy: Efficacy was assessed using the subjects' self-evaluation of PI and pain management collected on subject diaries (Days 0 to 5), the Modified Brief Pain Inventory (Days 1 to 5), and the subjects' use of concomitant rescue analgesic medication (Days 0 to 14). The primary efficacy endpoints were PI and pain control. The secondary efficacy endpoints were worst and least pain scores, rescue analgesia usage, function, overall treatment satisfaction, and individual PI scores over time.

Safety: Safety evaluations included AEs; assessments of laboratory tests such as chemistry, hematology, and urinalysis; a serum pregnancy test (if applicable); periodic monitoring of vital signs; 12 lead electrocardiogram (ECG); concomitant medications; and physical examinations. Evaluations also included surgical site healing and local tissue conditions.

Statistical Methods:

Tables and listings were produced using SAS version 8.2. All efficacy and safety data collected on the case report form (CRF) were presented in listings ordered by treatment group, site, subject number, date, and time. Data summaries by treatment group were presented. For continuous variables, data were summarized with the number of subjects (n), mean, standard deviation (SD), median, minimum, and maximum by treatment group. For categorical variables, data were tabulated with number and proportion of subjects for each category by treatment group.

Statistical tests were performed using 2-sided tests at the 5% significance level. Because of the exploratory nature of this Phase 2 study, no multiplicity adjustment was made for any of the analyses.

The comparison of primary interest was between Treatment 5 and Pooled Placebo. The significance of comparisons between Formulation A, Treatment 2 and Treatment 1 and Pooled Placebo were also reported.

The incidence (number and percentage) of treatment-emergent AEs was reported for each treatment group by Medical Dictionary for Regulatory Activities (MedDRA) Version 8.0 system organ class and preferred term. A separate overall incidence summary was presented for AEs with onset on Day 0.

Specific safety evaluations of the Modified Brief Pain Inventory were tabulated by study day and treatment. Incidence across all study days was also summarized by treatment.

Surgical site healing and local tissue condition evaluation was summarized and tabulated by subject incidence (n and percent) for each treatment group over time.

All laboratory test results were listed by subject, laboratory panel and parameter, and collection time.

Abnormal or change from screening physical examination results were presented in a listing.

Vital signs were listed descriptively for each treatment group at each collection time point. Changes from baseline (predose) vital signs were summarized for each treatment and scheduled interval. Repeat readings were not used in these summaries.

Screening and unscheduled ECGs were presented in a listing.

Results Efficacy Results:

The results of the per-protocol (PP) population analysis showed that, for the primary endpoint of PI during movement, the Formulation A treatment groups were not significantly better than the pooled Placebo group. Treatments 1 (5.0 mL Formulation A, subcutaneous) and 2 (5.0 mL Formulation A, subaponeurotic) were numerically better than placebo, but these differences did not reach statistical significance. For the primary endpoint of PI at rest, similar results were observed. The only statistically significant difference represented a higher PI value in Treatment 5 (5.0 mL Formulation A) compared to Pooled Placebo (P=0.014). In the analysis of secondary endpoints, the time to first rescue analgesia was significantly longer for Treatment 2 (5.0 mL Formulation A, subaponeurotic) than for Pooled Placebo (P=0.009).

A post hoc analysis of PI over time was conducted for the 2 cohorts separately. In Cohort 1, pain assessments were not significantly different between the 3 treatment groups. The Formulation A subaponeurotic and subcutaneous treatment groups required less opioid use during the evaluation period compared to placebo. In Cohort 2, no trend in reduction of overall cumulative opioid rescue medication use in the Formulation A treatment groups versus placebo was observed.

Safety Results:

The overall frequency of adverse effects (AEs) was similar between treatment groups. The most commonly reported treatment-emergent AEs were nausea (46 events total; 6 in Treatment 1, 10 in Treatment 2, 12 in Treatment 5, 1 in Treatment 5a, and 17 in Pooled Placebo), dizziness (42 events total; 4 in Treatment 1, 5 in Treatment 2, 13 in Treatment 5, 0 in Treatment 5a, and 20 in Pooled Placebo), constipation (40 events total; 5 in Treatment 1, 7 in Treatment 2, 15 in Treatment 5, 0 in Treatment 5a, and 13 in Pooled Placebo), and somnolence (38 events total; 4 in Treatment 1, 2 in Treatment 2, 13 in Treatment 5, 1 in Treatment 5a, and 18 in Pooled Placebo). The majority of treatment-emergent AEs were of mild or moderate severity. There were no deaths or discontinuations due to AEs. Three severe adverse effects (SAEs) occurred (syncope vasovagal, orthostatic hypotension, and oliguria); all of these events were moderate in intensity and none were considered related to study drug by the investigator.

An analysis of specific safety evaluations of interest did not indicate any opioid-related safety issues. Nausea, somnolence, dizziness, and constipation were reported by approximately 50% of subjects in all treatment groups. Vomiting, tinnitus, pruritus, dysgeusia, and paresthesia also occurred with high frequency. There were several differences in the frequency of occurrence of these events between the Formulation A and Pooled Placebo treatment groups: vomiting occurred in 7 subjects ( 7/40, 17.5%) in the Formulation A treatment group compared to 3 subjects ( 3/35, 8.6%) in the placebo group; dysgeusia occurred in 3 subjects ( 3/40, 7.5%) in the Formulation A treatment group compared to 6 subjects ( 6/35, 17.1%) in the placebo group; and paresthesia occurred in 4 subjects ( 4/40, 10.0%) in the Formulation A treatment group compared to 7 subjects ( 7/35, 20.0%) in the placebo group.

Post hoc analyses of specific safety evaluations of interest showed a decreased incidence of opioid-related side effects with Formulation A treatment in Cohort 1. The frequency of the nervous system disorders of dizziness and somnolence was less in the Formulation A treatment groups compared to placebo. Specifically, the frequency of dizziness was 64.3% in the placebo group, 27.8% in the Formulation A subaponeurotic treatment group (Treatment 2), and 30.8% in the Formulation A subcutaneous treatment group (Treatment 1). The frequency of somnolence was 50.0% in the placebo group, 11.1% in the Formulation A subaponeurotic treatment group (Treatment 2), and 30.8% in the Formulation A subcutaneous treatment group (Treatment 1). This decreased incidence of opioid-related side effects correlates with a reduction in opioid use in the Formulation A treatment group compared to placebo.

Conclusions

The primary specified analysis, while numerically better than placebo, did not provide statistical support for the overall hypotheses of efficacy. The results of the post hoc analyses in Cohort 1 showed that the frequency of opioid-related side effects was reduced in the Formulation A treatment groups compared to placebo, which corresponded to a reduction in opioid use in the Formulation A treatment groups compared to the placebo group. Furthermore, these post hoc analyses showed a reduction in pain within the first postoperative day in the Formulation A subaponeurotic treatment group compared to the placebo group, while no difference in pain scores was observed between the Formulation A subcutaneous treatment group and the placebo group.

The present invention having been thus described, variations and modifications thereof as would be apparent to those of skill in the art will be understood to be within the scope of the appended claims. 

1. A method of producing analgesia in a subject having arthroscopic subacromial decompression surgery, comprising: drawing up 5 mL of a bupivacaine composition into a 5 mL syringe using a 16-gauge or larger bore needle to fill the syringe, the bupivacaine composition comprising bupivacaine free base or salt thereof; discarding the 16-gauge or larger bore needle; and administering the 5 mL of the bupivacaine composition into the subacromial space of the subject using an 18-gauge or larger bore needle to produce post-surgical analgesia.
 2. A method of reducing or eliminating opioid consumption in a subject having arthroscopic subacromial decompression surgery, comprising: drawing up 5 mL of a bupivacaine composition into a 5 mL syringe using a 16-gauge or larger bore needle to fill the syringe, the bupivacaine composition comprising bupivacaine free base or salt thereof; discarding the 16-gauge or larger bore needle; and administering the 5 mL of the bupivacaine composition into the subacromial space of the subject using an 18-gauge or larger bore needle to produce post-surgical analgesia.
 3. The method of claim 1, further comprising storing the bupivacaine composition at a temperature ranging from 15° C. to 30° C. prior to the drawing up.
 4. The method of claim 1, wherein the bupivacaine composition is stored in a clear, glass vial prior to the drawing up.
 5. The method of claim 1, wherein the bupivacaine composition is stored in a 5 mL single-dose vial prior to the drawing up.
 6. The method of claim 1, wherein the bupivacaine composition is stored in a vial packaged in a carton prior to the drawing up.
 7. The method of claim 6, wherein ten of the vials are packaged in the carton, which is a 10-unit carton. 8-25. (canceled)
 26. The method of claim 1, wherein the bupivacaine composition comprises at least one of: 2,6-dimethylaniline, wherein the 2,6-dimethylaniline is present in the bupivacaine composition at a level less than 500 ppm, N-oxide of the active pharmaceutical agent, wherein the N-oxide of the active pharmaceutical agent is present in the bupivacaine composition at a level less than 1 wt %, based on weight of the bupivacaine composition, a metal, wherein the metal is present in the bupivacaine composition at a level less than 5 ppm, water, wherein the water is present at a level less than 0.5 wt %, based on weight of the bupivacaine composition, benzyl acetate, wherein the benzyl acetate is present in the bupivacaine composition at a level less than 100 mg/mL, and benzyl isobutyrate, wherein the benzyl isobutyrate is present in the bupivacaine composition at a level less than 50 mg/mL. 